THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 

GIFT  OF 

Dr.  Robert  B,  Portis 


LA    LJoWli) 

/'\./'\ILTOM  POffflS 


CANCER  OF  THE  STOMACH 


CANCER    OF    THE 
STOMACH 


A.  W.  MAYO  ROBSON,  D.Sc,  F.R.C.S. 

MEMBER  OF  COUNCIL  ROYAL  COLLEGE  OF  SURGEONS  ;  VICE-PRESIDENT  ROTAL  COLLEGE 

OP   SURGEONS,    1903-3    AND    1904^5;     HUNTERIAN    PROFESSOR    OF    SURGERY   AND 

PATHOLOGY,  1897,  1900  AND  1904;    BRADSHAW  LKCTUKEK,  1905;  HON.  SURGEON 

DREADNOUGHT    HOSPITAL    AND    LECTURER    LOXDON    SCHOOL    OF    CLINICAL 

MEDICINE,  1906;    CONSULTING  SURGEON  TO  THE  GENER4L  INFIRMARY 

AT    LEEDS,    AND    TO    THE    KEIGHLEY    AND    BATLEY    HOSPITALS  ; 

HON,    FELLOW    AMERICAN    SURGICAL    SOCIETY;     HON.    MEMBER    FRENCH    SURGICAL 

SOCIETY  ;    EMERITUS  PROFESSOR  OF  SURGERY  IN  THE  LEEDS  UNIVERSITY;    HON. 

PRESIDENT    INTERNATIONAL     MEDICAL     CONGRESS,     PARIS,     1900,     AND 

LISBON,    1906  ;     PRESIDENT    d'HONNEUR    INTERNATIONAL 

CONGRESS    OF   SURGERY,    1905 


NEW  YORK 

WILLIAM  WOOD  AND  COMPANY 

MDCCCCVII 


PRINTED    IN    LONDON,    ENGLAND 


Bidmedica) 
Library 


lOI 

K57bc 

PREFACE 


TN  responding  to  the  Editor^s  request  to  write  a 
small  work  on  Cancer  of  the  Stomach  for  the 
Nisbet  Modern  Clinics  Series,  I  have  tried  to  carry 
out  his  wish  to  make  it  practical  and  useful.  In 
doing  this  it  will  be  noticed  that  I  have  omitted 
much  that  might  have  been  written  on  the  pathology 
of  the  subject,  and  in  other  ways  have  laid  myself 
open  to  criticism ;  but  if  it  proves  helpful  to  the  busy 
practitioner  and  furthers  in  any  way  the  early  re- 
cognition and  early  surgical  treatment  of  the  disease, 
I  shall  have  accomplished  my  purpose. 

A.  W.  M.  R. 

8,  Park  Crescent, 

London,  W. 


6760^S 


CONTENTS 


CHAPTER  PAGE 

I.    Introduction  with  some  G-eneral  Eemarks 

ON  Cancer          ......  1 

II.    Surgical  Anatomy  of  the  Stomach  .  10 

III.  General  Diagnosis  of  Stomach  Diseases, 

INCLUDING  Cancer 22 

IV.  Cancer  of  the  Stomach      ....  44 


V.    Simple    Tumours    of    the    Stomach    that 
MAY  BE  Mistaken  for  Cancer 

VI.    Sarcoma  of  the  Stomach   . 

VII.    Dilatation  of  the  Stomach 

VIII.    Operations  for  G-astric  Cancer 

IX.     GtASTRECTOMY  ..... 

X.   Indications     for    the    Performance    of 
Gastro-enterostomy  in  Malignant  Dis 

EASE    OF    THE    StOMACH 

XI.    Gastrostomy  ..... 

XII.    Jejunostomy 

XIII.    Gastro-cesophagostomy 

Index  ....... 


93 
105 
109 
117 
124 

147 
188 
202 
210 
215 


CANCER  OF  THE  STOMACH 


CHAPTER    I 

INTRODUCTION    WITH  SOME  GENERAL 
REMARKS  ON  CANCER 

It  would  seem  hardly  necessary  to  find  any  excuse 
for  the  publication  of  a  monograph  on  cancer  of  the 
stomach  and  its  treatment^  for  when  it  is  realised  how 
frequent  gastric  cancer  is  and  that  the  disease  is  at 
first  local  and  curable  in  a  considerable  proportion  of 
cases  by  early  removal;  the  stomach  being  in  fact 
invaded  more  frequently  than  any  other  organ 
accessible  to  direct  observation^  it  is  curious  that 
surgical  treatment  of  this  disease  has  not  yet 
received  more  attention. 

Though  caucer  is  distinctly  amenable  to  treatment 
and  is  probably  really  curable  if  radically  treated  in 
its  early  stages,  yet  the  fact  remains  that  though 
frequently  relieved   it  is  very  seldom  actually  cured. 

1 


2  CANCER   OF   THE   STOMACH 

The  explanation  of  this  anomaly  can  only  be 
ignorance  or  prejudice  ;  for  clinical  observers,  both 
medical  and  snrgical_,  in  various  parts  of  the  world 
have  for  some  years  not  only  been  writing  on  the 
subject  and  trying  to  convince  the  profession  and 
the  public  of  the  needs  and  the  possibilit}^  of  an 
early  diagnosis  with  a  view  to  successful  radical 
treatment_,  but  they  have  also  clearly  demonstrated 
the  possibility  of  successfully  practising  what  they 
have  preached  both  Avith  regard  to  diagnosis  and 
treatment. 

As  regards  the  frequency  of  carcinoma  of  the 
stomach,  Dr.  C.  N.  Dowd  {Medical  Record,  1906) 
called  attention  to  the  fact  that  according  to  the 
census  reports  there  were  no  less  than  9000  deaths 
from  cancer  of  the  stomach  in  the  United  States  in 
1900,  and  of  these  very  few  had  been  submitted 
to  surgical  treatment.  I  find  on  referring  to  the 
Registrar-GeneraPs  report  for  England  and  AVales 
that  during  the  years  1901—1904  no  less  than 
19,607  deaths  from  cancer  of  the  stomach  were 
registered,  equal  to  4901  per  annum.  Professor 
Osier  has  pointed  out  that  in  the  years  1901—1905, 
while  there  were  24,750  deaths  from  cancer  of  the 
stomach  there  were  only  19,675  from  cancer  of  the 
uterus,  and  14,418  from  cancer  of  the  breast. 

Sanitarians  and  statisticians,  English  and  foreign, 
have  called  attention  to  the  marked  increase  in  the 
mortality  from  cancer,  at  the   same   time  that  there 


INTRODUCTION  3 

lias  been  a  gratifying  decrease  in  the  deatli  rate  from 
infectious  disease.  In  England  during  the  last  thirty 
years  the  recorded  death  rate  from  cancer  has 
nearly  doubled^  while  in  America  it  has  almost  been  I 
trebled.  Doubtless  this  may  be  partly  due  to  greater  V 
accuracy  in  diagnosis^  for  the  increase  has  been 
largely  recorded  in  the  internal  organs  and  much 
less  in  accessible  parts.  But,  as  stated  by  Dr. 
Roger  Williams,  there  has  not  only  been  uniformity 
in  the  variations  of  the  increments  in  the  long 
accession  of  years,  but  the  increase  has  involved  all 
parts  of  the  body  without  material  alteration  in  the 
normal  proportionate  ratios  ;  moreover  the  increase 
has  been  recorded  in  most  civilised  countries. 

Tlio  importance  of  the  subject  is  arousing  wide- 
spread interest  both  within  and  outside  the  profession; 
and  not  only  at  home  but  also  abroad  large  sums 
of  money  are  being  granted  both  from  private  and 
public  sources  for  the  investigation  of  the  disease. 

Of  the  true  cause  of  cancer  we  really  know 
nothing;  even  if  we  could  accept  the  view  of  those 
jDathologists  who  consider  malignant  disease  as 
simply  due  to  an  alteration  of  somatic  into  generative 
elements  we  should  be  still  begging  the  cause  ;  nor 
can  we  accept  unreservedly  the  statement  of  a 
distinguished  authority  that,  from  the  histological 
character,  method  of  growth,  and  absence  of  specific 
symptomatology,  it  is  not  permissible  to  seek  for  the 
causative  factor  of  cancer    outside  the   life  processes 


4  CANCER   OF   THE   STOMACH 

of  the  cells_,  for  our  present  knowledge  does  not 
warrant  sucli  a  positive  statement ;  and  it  would 
appear  from  tlie  observations  of  several  competent 
pathologists  that  facts  are  not  incompatible  with  the 
theory  that  cancer  may  be  produced  by  an  intra-cel- 
lular  parasite  which  stimulates  the  cell  to  excessive 
multiplication.  The  fact  that  no  parasite  has  been 
hitherto  discovered  is  no  proof  that  the  quest  is 
hopeless,  and  should  be  no  deterrent  to  a  continuance 
of  research  work.  How  many  years  w^ere  spent  in 
fruitless  search  before  Koch  found  the  tubercle 
bacillus — a  discovery  that  has  placed  tuberculosis  on 
quite  another  platform,  and  one  which  bids  fair  to 
the  stamping  out  of  the  disease.  Does  anyone 
doubt  the  origin  of  measles  or  scarlet  fever  from 
organisms  ?  Yet  absolute  proof  is  still  wanting.  The 
origin  of  syphilis  has  only  just  been  revealed  by  the 
discovery  of  the  Spirocliaita  ijallida.  Recently 
Councilman  has  apparently  proved  that  vaccine 
bodies  form  one  phase  of  the  life-history  of  the 
protozoon  said  to  cause  smallpox,  and  Dr.  Roswell 
Park  and  Dr.  Gaylord  regard  the  cell  inclusions  in 
cancer  as  being  of  the  same  nature,  though  the 
presence  of  these  organisms  in  cancer  tissue  is, 
of  course,  no  proof  that  they  are  the  cause  of 
the  disease.  The  same  remarks  apply  to  Bosc's 
arguments  and  experiments  on  sporozoa.  That 
bacteria  are  not  the  only  possible  pathogenic 
parasites    the    history   of  malaria  has    proved.      We 


INTRODUCTION  5 

are  still  in  almost  total  ignorance  of  some  of  the 
lowest  forms  of  life  and  of  their  biological  peculiarities^ 
nor  are  we  sure  that  Koch\s  laws  will  be  valid  for 
them. 

Even  of  the  predisposing  causes  of  cancer  we 
know  next  to  nothing,  though  of  theories  there  are 
man3\  My  friend  the  late  Sir  AVilliam  Mitchell 
Banks  and  others  thought  overfeeding  might  afford 
an  explanation  ;  one  phj^sician  asserts  that  it  is 
uric  acid,  and  would  limit  the  intake  of  nitrogen  ; 
whereas  others  consider  it  due  to  an  excess  of 
carbohydrates,  and  suggest  that  starches  and  sugar 
should  be  limited.  The  teetotalers,  of  course,  find  in 
alcohol  a  possible  cause,  and  the  non-smokers  decr}^ 
tobacco.  Some  advise  us  to  eschew  salads  and 
all  uncooked  vegetables  and  others  would  have  us 
abolish  salt  as  an  article  of  diet.  In  fact,  there  is 
scarcely  any  form  of  diet  or  luxury  that  has  not  at 
one  time  or  another  been  condemned.  Do  not  all 
these  theories  make  one  feel  that  until  something- 
definite  is  found  out,  the  public  have  a  just  cause  of 
complaint  against  those  who,  on  insufficient  evidence, 
not  only  would  cut  oif  their  luxuries  one  by  one,  but 
would  even  tax  the  necessaries  of  life  with  suspicion  ? 

One  exciting    cause   only  we  are   certain    of,  and  y 
that    is   irritation  in    a  variety  of   forms.      Another  ( 
fact   we   can   absolutely    prove  is  that   cancer   is   at 
first  a  local  disease,  and   only  later  a  constitutional 
malady.      Mr.  -Jonathan  Hutchinson  insisted   on  this 


6  CANCER    OF   THE   STOMACH 

thirty  years  ago,  and  it  has  been  confirmed  by 
modern  research,  as  tlie  following  statement  by 
Dr.  Bashford  will  show  : 

"  Our  observations  on  animals  show  that  malignant 
growths  are  alwa3^s  local  in  origin,  and  of  themselves 
produce  no  evident  constitutional  disturbance  what- 
ever. These  facts  are  in  full  accord  w^ith  accumu- 
lated clinical  experience  in  man.^^ 

Cancer  is  undoubtedly  auto-infective,  hence  the 
danger  of  an  imperfect  operation,  which,  by  distribu- 
ting the  cancer  cells,  implants  numerous  foci  of 
disease.  I  recently  saw  a  marked  example  of  such 
a  condition  in  a  patient  who  consulted  me  with  a 
view  to  operation.  She  gave  the  history  of  having 
had  a  cancer  removed  from  the  breast  over  three 
3^ears  previously  by  a  radical  operation  ;  at  the  end 
of  that  period  a  small  lump  was  noticed  in  the  clavi- 
cular portion  of  the  pectoral  muscle,  the  skin  being 
healthy  and  non-adherent.  A  surgeon  removed  the 
muscle,  including  the  lump,  but  finding  enlarged 
glands  at  the  top  of  the  axilla  he  attempted  to  get 
them  away  by  digital  enucleation,  with  the  result 
that  they  burst  and  infected  the  whole  of  the  wound, 
which,  however,  healed  by  first  intention.  Within 
two  months  every  needle  puncture  was  the  site  of  a 
small  cancerous  nodule,  and  numerous  other  nodules 
appeared  over  the  chest  wall  and  over  the  clavicle 
and  shoulder,  leading  to  a  rapidly  fatal  termination. 
We  must  all  have  seen  similar  cases,  and  the  lesson 


INTRODUCTION  7 

conveyed  is  tliat_,  if  possible,  cancerous  tumonrs  should 
be  removed  without  preliminary  incision,  leaving  a  wide 
area  of  healthy  tissue  around  the  growths,  and  wher- 
ever practicable  the  nearest  lymphatic  glands  and 
vessels  going  to  them  should  be  removed,  whether 
enlarged  or  not.  If  the  glands  be  already  infected 
it  is  of  the  utmost  importance  that  they  should  be 
taken  away  cleanly  without  rupture,  and  wherever 
possible  in  the  same  piece  as  the  tumour.  If  for 
diagnostic  purposes  the  tumour  has  to  be  incised, 
the  exploratory  incision  should  be  closed  by  sutures, 
the  skin  purified,  the  knife  and  needles  boiled  and 
the  surgeon^s  hands  sterilised  before  proceeding 
with  the  operation.  If,  unfortunately,  the  wound 
has  become  soiled,  it  should  be  irrigated  with  a 
large  quantity  of  saline  solution  or  some  antiseptic 
lotion,  so  as  to  wash  away  any  loose  masses  of 
cancer  cells  or  infective  material,  which  if  left  will 
probably  become  engrafted  and  grow  as  in  the  case 
that  I  have  mentioned. 

My  friend  Dr.  W.  J.  Mayo,  of  Rochester,  U.S.A.,  tl 
insists  on  the  importance  of  searing  the  edges  of  the 
stomach  wound  with  the  actual  cautery  after  par- 
tial gastrectomy,  in  order  to  avoid  leaving  any  in- 
fected surface  after  the  removal  of  a  gastric  cancer ;  \ 
and  the  importance  of  that  I  would  strongly  empha- 
sise should  it  be  necessary  to  incise  the  gastric  wall 
near  the  growth,  though  when  the  incision  is  made 
wide    of    the    tumour    this  is    no    longer    necessary. 


8  CANCER    OF   THE   STOMACH 

Some  English  surgeons  apply  absolute  phenol  for 
the  same  reason  to  any  doubtfully  infected  sur- 
face after  removal  of  a  cancerous  tumour.  So  long 
as  the  tumour  is  not  ulcerated  it  is  probably  not 
contao'ious,  but  from  the  moment  that  ulceration 
occurs  transmission  to  the  patient  or  others^  granted 
a  suitable  medium_,  may  be  possible.  Such  trans- 
mission is,  however,  probably  rare,  as  the  conditions 
necessary  to  a  successful  transmission  must  be 
difficult  to   realise. 

The  following  facts  among  others  that  could  be 
related  seem  to  prove  without  doubt  the  auto-infec- 
tivity  of  ulcerated  cancer.  "Williams  {British 
Medical  Journal,  1887,  p.  1369)  relates  a  case  of 
an  ulcerating  cancer  of  one  thigh  infecting  the 
opposite  thigh  b}^  contact.  Cripps  reported  a  case 
of  ulcerating  cancer  of  the  breast  infectino*  the  skin 
of  the  inner  side  of  the  arm,  where  it  had  come  in 
contact  with  the  growth.  Roswell  Park,  Waldegar, 
Quincke,  myself,  and  others,  have  seen  cancer  to 
involve  the  whole  length  of  the  trocar  puncture 
after  tapping  for  ascites  due  to  abdominal  cancer. 
I  have  seen  the  needle  punctures  and  the  adjoining- 
skin,  previously  healthy,  to  become  infected  after 
the  removal  of  cancer  of  the  ovary,  and  Sippal  has 
quoted  some  similar  cases.  I  have  seen  and  others 
have  reported  cases  of  a  supra-pubic  drainage 
opening  becoming  infected  after  removal  of 
epithelioma    of    the    bladder.       Hurry   Fenwick    has 


INTRODUCTION  9 

noted  its  transmission  from  one  surface  to  another 
of  the  bladder^  an  observation  wliicli  I  can  also  con- 
firm. I  have  heard  of  a  case  where  an  epithelioma 
of  a  projecting  lower  lip,  which  could  just  touch  the 
tip  of  the  nose  in  an  edentulous  old  man,  gave  rise 
to  a  similar  growth  on  the  tip  of  the  nose,  and  I 
have  seen  a  second  epithelioma  to  arise  on  the  upper 
lip  opposite  to  an  epithelioma  of  the  lower  lip,  and 
a  growth  to  arise  inside  the  cheek  opposite  to  an 
epithelioma  of  the  jaw  and  also  opposite  to  one  of 
the  tongue.  Schimmelbusch  has  reported  cancerous 
infection  of  the  lip  through  the  finger-nails  of  a 
patient  who  was  handling  his  cancerous  ear. 

It  would  form  an  interesting  subject  for  inquiry 
to  ascertain  how  often  cancer  of  the  stomach  follows 
on,  or  accompanies  cancer  of  the  oesophagus  and  cancer 
of  the  tongue  and  mouth  owing  to  the  swallowing  of 
cancerous  particles.  Such  cases  have  been  reported  by 
Cornil,  Klebs,  Lurcke,  and  Menetrier.  That  the 
two  are  often  associated  is  recognised,  but  I  suspect 
that  the  association  is  more  frequent  than  is  generally 
supposed. 

From  these  observations  it  seems  highly  probable 
that  cancer  is  both  contagious  and  inoculable  under 
certain  rare  conditions  among  human  beings,  as  it 
undoubtedly  is  among  tjie  lower  animals. 


CHAPTER    II 
SURGICAL  ANATOMY  OF  THE  STOMACH 

Although  it  is  imnecessaiy  to  give  a  complete 
anatomical  description  of  tlie  stomach,  yet  some 
consideration  of  its  surgical  anatomy  is  called  for  in 
dealing  with  any  branch  of  gastric  surgery.  Under 
pathological  conditions  there  is  no  organ  of  the  body 
which  varies  so  much  in  size,  position  and  relations 
as  the  stomach.  When  relaxed  (as  it  is  usually 
seen  when  operating  or  at  fost-mortem  examination) 
it  is  a  somewhat  pear-shaped,  hollow  organ  situated 
in  the  left  hypochondriac  and  epigastric  regions, 
covered  in  two  thirds  of  its  extent  by  the  liver  and 
diaphragm  and  to  the  extent  of  one  third  by  the 
anterior  abdominal  wall  and  reaching  to  within  two 
inches  of  the  umbilicus  ;  but  it  may  be  so  contracted 
in  certain  cases  of  stricture  of  the  oesophagus  as  to 
lie  away  from  the  surface,  completely  under  cover  of 
the  liver  and  diaphragm  ;  or  it  may  be  so  dilated  in 
some  cases  of  stricture  of  the  pylorus  as  to  occupy 


SURGICAL   ANATOMY   OF    STOMACH     11 

every  region  of  the  abdomen  and  to  extend  into  the 
true  pelvis. 

The  general  axis  is  inclined  obliquely  downwards 
and  to  the  right  from  the  only  normally  fixed  part^ 
the  cardiac  orifice ;  but  the  axis  may  be  almost 
vertical  as  in  some  cases  of  gastroptosis,  or  hori- 
zontal as  in  some  cases  in  which  the  pylorus  is 
fixed  to  the  under  surface  of  the  liver  by  adhesions^ 
or  by  a  short  gastro-hepatic  mesentery.  The  car- 
diac orifice  is  situated  at  the  back  of  the  abdomen  on 
the  left  of  the  tenth  dorsal  vertebra,  which  spot  corre- 
sponds in  front  with  the  junction  of  the  seventh  left 
costal  cartilage  to  the  sternum.  The  pyloric  outlet 
is  normally  situated  to  the  right  of  the  eleventh  and 
twelfth  dorsal  vertebra?,  and  when  the  stomach  is 
empty  the  pylorus  lies  2  inches  below,  Ih  inches  to  the 
right  and  H  inches  in  front  of  the  cardiac  orifice; 
but  when  the  stomach  is  distended  the  pylorus  lies 
2i  to  3  inches  to  the  rio-lit  and  2  inches  in  front 
of  the  cardia,  it  being  normally  movable  over  a 
limited  range. 

The  pylorus  may,  however,  be  firmly  fixed  to  the 
under  surface  of  the  liver  by  adhesions,  or  so  freely 
movable  that  when  it  is  the  seat  of  tumour  it  may 
be  made  to  reach  into  every  region  of  the  abdomen, 
and  I  have  even  seen  it  in  the  pelvis. 

As  seen  2)ost  nnortem  (if  hardened  by  formalin) 
the  pyloric  aperture  projects  into  the  duodenum 
and   resembles    the    external    os    uteri,    the    pyloric 


12  CANCER   OF   THE    STOMACH 

portion  of  the  stomach  being  contracted  to  the   size 
of  the  small  intestine. 

I  The  p3'lorus  is  normally  closed,  except  when  food 
is  passing,  but  an  examination  of  the  pylorus  in  a 
large  number  of  living  subjects  during  operation 
has  convinced  me  that  j)ost-mortem  findings  are  not 
always  safe  to  argue  from  in  the  living,  for  I  have 
ver}^  frequently  found  the  pylorus  patulous  and 
readily  permitting  the  passage  of  the  forefinger 
when  the  stomach  was  empty.  It  may  be  so  con- 
tracted in  disease  as  to  barely  admit  the  passage  of 
a  probe,  or  rarely  it  may  be  found  so  patulous 
as  to  permit  two  fingers  to  pass. 

A  description  of  the  stomach  would  not  be  com- 
plete without  mentioning  the  fact  that  under  the 
influence  of  peristalsis  the  shape  of  the  stomach  is 
not  a  thin-walled,  flaccid  sac,  corresponding  to  the 
usual  description  as  seen  in  the  dissecting  room,  for 
when  contracting  it  ma}^  be  seen  to  be  composed  of  a 
cardiac  division  somewhat  globular  in  shape  and  a 
pyloric  portion  resembling  thick-walled  intestine. 

W.  D.  Cannon  (American  Journal  of  Physiology, 
1898,  vol.  i,  p.  359)  fed  cats  with  pulpy  food 
impregnated  with  subnitrate  of  bismuth,  and  then 
observed  the  movement  of  the  stomach  contents 
by  means  of  the  Rontgen  rays.  In  this  way  the 
saccular  cardiac  portion  and  the  tubular  p^doric 
portion  were  clearly  demonstrated.  He  found  the 
fundus    to     be    an    active    reservoir    for    the    food, 


PLATE    I. 


PC. 


t 


''3S. 


Stonir.ch  of  an  adult  female  in  an  early  stage  of  the  emptyino-  process. 


■Q.S. 


Rv>-.: 


stomach  of  an  adult  male  showing  tlic  division  into  a  cardiac  sac 
and  a  yastiic  tube. 


Tofdcfj).   I'.i, 


AtJhtrd  .1    Sou,  Inipt 


SUIIGICAL   AN2VTOMY   OF   STOMACH     13 

squeezing  its  contents  gradually  into  tlie  pyloric 
part,  wliicli  tlien  contracted  on  it  Ly  a  series  of 
peristaltic  waves.  Each  wave  took  about  tliirty-six 
seconds  to  pass  from  tlie  middle  of  the  stomach 
to  the  pylorus  and  the  different  waves  folloAved 
each  other  at  intervals  of  ten  seconds.  As  they 
passed  the  incisura  angularis  the  indentation  in 
the  lesser  curvature  became  deeper.  The  cardiac 
sac  did  not  take  part  in  the  active  peristaltic 
wave,  but  seemed  to  squeeze  its  contents  gradu- 
ally into  the  pyloric  part. 

Hirsch  and  Cannon  have  shown  that  the  discharge 
of  food  takes  place  intermittently  at  irregular 
intervals  according  to  the  condition  of  the  food  which 
reaches  the  pyloric  canal. 

This  functional  division  of  the  stomach  is  clearly 
shown  in  the  a^^pended  drawing  copied  from  Cunning- 
ham's paper,  "  Varying  Form  of  the  Stomach  in  Man 
and  the  Anthropoid  Ape"  (Transactions  of  the  Royal 
Society  of  Edinhtirgh,  1906,  vol.  xlv,  Part  1,  No.  2). 

The  stomach  has  two  borders  and  two  surfaces. 
The  upper  border  is  known  as  the  lesser  curvature  ; 
it  extends  from  the  cardiac  orifice  to  the  pylorus  and 
is  from  three  to  four  inches  in  length  ;  it  is  slightly 
concave  from  above  downwards  and  to  the  right,  and 
is  nearly  altogether  on  the  left  of  the  spine. 

The  greater  curvature  is  about  three  times  the 
length  of  the  lesser,  and  is  convex  throughout  except 
a  small  portion  near   the  pylorus ;  it   commences  on 


14  CANCER   OF   THE    STOMACH 

the  left  of  tlie  cardiac  orifice  and  avclies  upwards 
over  the  dome  of  the  stomach  to  the  left^  then  passes 
downwards  and  to  the  right_,  bending  upwards 
again  to  reach  the  p3dorus. 

The  surfaces  are  commonly  spoken  of  as  anterior 
and  posterior,  and  when  the  stomach  is  empty  this 
is  correct ;  but  when  distended  the  position  is  altered 
so  that  the  anterior  surface  looks  upward  as  well  as 
forwards  and  the  posterior  downwards  and  back- 
wards. 

The  anterior  surface  is  in  contact  above  Avith  the 
left  lobe  of  the  liver  and  diaphragm  and  below  with 
the  abdominal  wall  in  the  epigastric  region. 

The  posterior  surface  rests  on  the  transverse  colon 
with  its  meso-colon,  the  pancreas^  the  left  kidney  and 
supra-renal  body  and  the  large  vessels. 

The  stomach  chamber. — The  stomach  chamber  is  a 
well-defined  space  in  the  upper  abdomen  occupied 
by  the  stomach.  It  has  a  sloping  floor  which  is 
known  as  the  stomach  bed,  composed  of  the  front  of 
the  left  kidney,  the  left  supra-renal  capsule_,  the 
gastric  surface  of  the  spleen,  the  upper  surface  of 
the  pancreas,  the  transverse  colon  and  the  meso- 
colon, the  lesser  sac  of  the  peritoneum  intervening 
between  these  and  the  wall  of  the  stomach  except 
for  a  small  area  near  the  cardiac  end  where  the 
stomach  lies  in  direct  contact  with  the  diaphragm 
above  the  left  supra-renal  body.  The  roof  of  the 
stomach  chamber  is   dome-like    and    is    formed    by 


SURGICAL   ANATOMY   OF    STOMACH     15 

part  of  the  under  surface  of  the  liver,  the  left  cupola 
of  the  diaphragm  and  the  anterior  abdominal  wall. 

It  is  interesting  to  note  that  a  part  of  the  under 
surface  of  the  heart;  near  the  apex,  is  only  separated 
from  the  stomach  by  the  pericardial  sac,  the  left 
cupola  of  the  diaphragm  and  the  peritoneum. 

The  gastro-hepatic  omentum,  composed  of  two 
peritoneal  layers,  extends  between  the  lesser  curvature 
of  the  stomach  and  the  liver,  and  in  its  right  border, 
which  is  free,  run  the  common  bile-duct,  portal  vein 
and  hepatic  artery,  this  free  border  with  its  contents 
forming  the  front  boundary  of  the  foramen  of  AVinslow. 

If  this  suspensory  ligament  of  the  stomach  is  abnor- 
mally long  it  allows  the  stomach  to  descend  below  its 
normal  level,  giving  rise  to  gastroptosis,  in  which  case 
the  pancreas  can  be  seen  through  the  peritoneal  folds 
above  the  lesser  curvature  of  the  stomach. 

The  gastro-phrenic  omentum  is  a  small,  double 
fold  of  omentum  extending  between  the  upper  border 
of  the  stomach  on  the  left  of  the  cardiac  orifice  and 
the  diaphragm. 

The  gastro-splenic  omentum  is  a  double  layer  of 
peritoneum  extending  between  the  left  border  of  the 
great  curvature  of  the  stomach  and  the  spleen.  It  con- 
tains between  its  folds  the  left  gastro-epiploic  artery. 

The  great  omentum  is  formed  by  the  meeting  of 
the  two  layers  of  peritoneum  which  have  enveloped 
the  stomach  and  united  at  the  lower  border,  whence 
it  extends   downwards   like   a    veil   in    front    of   the 


16  CANCER   OF   THE    STOMACH 

transverse  colon  and  small  intestine,  returning  to 
the  transverse  colon,  wliicli  it  encloses ;  it  then 
passes  back  to  the  spine  as  the  transverse  meso- 
colon, an  important  structure  in  the  operation  of 
posterior  gastro  -  enterostomy.  The  stomach  is 
thus  enveloped  by  a  single  layer  of  peritoneum,  the 
two  layers  of  omentum  splitting  to  enclose  it,  and 
unitino:  below  to  form  the  o-reat  omentum. 

The  investment  is  intimate  everywhere  excej^t 
at  the  margins,  along  which  the  large  vessels  run 
tortuously,  loosely  enveloped  in  the  cellular  tissue 
intervening  between  the  two  peritoneal  layers. 

The  muscular  coat  consists  of  unstriped  muscular 
fibres  arranged  in  three  more  or  less  distinct  layers, 
longitudinal,  circular  and  oblique.  Of  these  three 
that  which  is  of  special  interest  is  the  middle  layer. 
This,  toward  the  pylorus,  becomes  thicker  and  stronger 
and  when  it  reaches  the  exit  from  the  stomach  the 
circular  fibres  are  heaped  up  so  as  to  project  inward 
into  the  lumen  of  the  passage  and  form  a  distinct 
sphincter.  Under  normal  circumstances  the  calibre 
of  the  pyloric  orifice  has  a  diameter  of  rather  less 
than  half  an  inch,  this  diminution  in  the  calibre 
being  caused  entirely  by  the  increase  of  the  circular 
muscular  fibres,  the  bulk  of  the  longitudinal  fibres 
taking  no  part  in  the  process,  but  passing  on  into 
the  first  part  of  the  duodenum,  some  of  them,  how- 
ever, dipping  in  to  join  the  circular  fibres. 

The  submucous  coat  is  composed  of  areolar  tissue. 


SURGICAL   ANATOMY   OF    STOMACH      17 

and  is  the  tunic  in  wliicli  the  larger  arterioles 
break  up.  The  submucous  tissue  does  not  bind 
tlie  mucous  membrane  very  closely  to  the  mus- 
cular layer,  but  permits  considerable  sliding  of 
one  coat  upon  the  other. 

The  mucous  membrane^  which  is  thickest  in  the 
pyloric  region  and  thinnest  in  the  great  sac,  is  richly 
supplied  with  glands.  The  whole  interior  of  the 
stomach  is  covered  by  a  single  layer  of  columnar 
epithelial  cells.  Scattered  throughout  the  mucous 
membrane,  but  most  abundant  towards  the  pylorus, 
are  small  masses  of  lymphoid  tissue,  which  are  of 
importance  as  occasionally  ulcerating  in  Hodgkin's 
disease. 

The  blood  supply  of  the  stomach,  which  is  very 
free,  is  from  the  three  branches  of  the  coeliac  axis. 
The  coronary  artery  of  the  stomach  reaches  the 
viscus  at  the  cardiac  end,  and  after  giving*  off 
branches  to  the  lower  part  of  the  oesophagus  it 
runs  along  the  lesser  curvature  from  left  to  right, 
and  anastomoses  with  the  pyloric  branch  of  the  hepatic 
artery.  From  the  hepatic  artery  two  branches  sup- 
ply the  stomach.  The  smaller  of  these^  the  pyloric 
branch,  reaches  the  stomach  at  the  upper  margin  of 
the  pylorus,  and  passes  towards  the  left  along*  the 
lesser  curvature  to  inosculate  with  the  terminal 
branches  of  the  coronary  artery.  The  larger,  the 
gastro-duodenal  artery,  passes  behind  the  first 
part  of  the  duodenum  close  to  the  pylorus,  and  after 


18  CANCEE    OF   THE   STOMACH 

giving  off  the  superior  pancreatico-duodenal  branch 
continues  from  right  to  left  along  the  greater 
curvature  of  the  stomach  as  the  right  gastro-epiploic 
artery.  The  splenic  arter}^  runs  along  the  upper 
margin  of  the  pancreas  from  right  to  left,  and 
supplies  several  small  branches  to  the  stomach  before 
it  gives  rise  to  the  left  gastro-epiploic  artery,  which 
lies  between  the  layers  of  the  gastro-epiploic  omentum, 
and  is  continued  along  the  great  curvature  of  the 
stomach  to  anastomose  with  the  terminal  branches 
of  the  right  gastro-epiploic  arter3^ 

From  the  two  arches  thus  formed  at  the  upper 
and  lower  margins  of  the  stomach  vessels  pass  at 
right  angles  to  supply  the  body  of  the  viscus.  The 
ultimate  branches  of  these  form  the  intricate  net- 
work of  the  interglandular  tissue,  and  from  the 
capillaries  round  the  mouths  of  the  glands  the  veins 
take  origin.  These  in  the  mucous  membrane  are  fewer 
but  larger  than  the  arteries.  They  form  a  plexus  in 
the  submucous  tissue,  and  then  pass  along  with  the 
arteries  to  form  larger  veins  corresponding  to  the 
large  arteries  already  described — viz.  coronary,  left 
and  right  gastro-epiploic  and  pyloric  veins.  These 
all  empty  into  the  portal  vein  either  directly,  as  in 
the  case  of  the  pyloric  and  coronary  veins,  or  by 
joining  the  superior  mesenteric  or  splenic  veins. 

In  Mikulicz's  clinic,  attention  was  drawn  to  the  fact 
that  part  of  the  venous  blood  from  the  stomach,  instead 
of  passing  through  the  portal  vein  so  as  to  be  sterilised 


SURGICAL    ANATOMY   OF    STOMACH     19 

by  tlie  liver^  is  returned  directly  through  the  vascular 
anastomoses   about   the    cardiac    orifice.      This  may, 


Fig.  1. — The  lymphatics  of  the  stomach.  (Modified  after  Cuneo). 
a,  b,  c,  glands  shown  by  J.  F.  Dohson  to  exist  in  the  splenic 
omentum  and  on  the  left  of  the  cardiac  orifice. 

perhaps,  account  for  some  cases  of  embolic  pneumonia 
in  stomach  diseases. 

The   lymphatics  of    the   stomach,   which  are  very 
numerous,  arise  in   intimate  relation  with  the  gland 


20  CANCER    OF   THE    STOMACH 

tubules.  The}'  form  a  plexus  of  dilated  lympli 
sinuses  in  the  submucous  tissue  and  then  pass 
toward  the  upper  and  lower  margins,  Avhere  they 
traverse  a  number  of  lymphatic  glands  which  lie 
along  the  gastric  borders  of  the  small  and  great 
omenta  respectively.  Thence  they  pass  to  the 
coeliac  glands  which  lie  beside  the  aorta  above  the 
origin  of  the  superior  mesenteric  artery,  those  of  the 
lesser  curvature  following  the  course  of  the  coronary 
vessels  until  the  cardiac  orifice  is  reached,  when  they 
turn  down  behind  the  pancreas  to  reach  the  coeliac 
glands.  Those  on  the  greater  curvature  run  with 
the  right  gastro-epiploic  vessels,  and  in  part  with 
the  splenic  vessels,  and  reach  the  same  lymphatic 
glands.  Thence  they  pass  together  with  the  vessels 
which  drain  the  mesenteric  glands,  to  open  into  the 
lower  end  of  the  thoracic  duct. 

The  dome,  to  the  left  of  the  cardiac  opening,  is 
much  less  freely  supplied  with  lymphatics  than  the 
body  and  pjdoric  section  of  the  stomach.  This  has  an 
important  bearing  when  considering  the  subject  of 
total  gastrectomy,  for  in  some  cases,  even  when  a 
great  part  of  the  stomach  is  affected  by  the  growth, 
it  may  be  safe  to  leave  a  portion  of  the  cardiac  end 
and  the  dome. 

The  nerves  of  the  stomach,  derived  from  the 
terminal  branches  of  both  pneumogastrics  and  from 
S3nnpathetic  branches  of  the  solar  plexus,  are  very 
al)un(lant,   and  not  only  account  for  the  very  severe 


SURGICxVL   ANATOMY   OF    STOMACH     21 

pain  caused  by  ulcoriitioii,  but  also  for  the  severe 
collapse  produced  by  injury,  tliougli  it  is  a  mistake 
to  suppose  that  manipulation  of  the  pylorus  is 
attended  by  the  severe  shock  suggested  by  the 
experiments  made  by  Dr.  Crile,  for  in  many  cases  I 
have  freely  handled  the  stomach  and  pylorus  and 
operated  on  them  without  the  patient  experiencing 
more  shock  than  would  be  expected  after  any  abdo- 
minal operation.  When  the  pylorus  is  adherent  and 
the  parts  have  to  be  much  dragged  on,  severe  shock 
is  not  infrequently  seen,  but  this  is  due  to  interfer- 
ence with  the  large  sympathetic  nerves  and  ganglia 
behind  the  pylorus. 

The  relation  of  the  sympathetic  nerves  with  the 
seventh,  eighth,  and  ninth  spinal  roots  accounts  for 
the  superficial  tenderness  of  the  epigastrium  in 
ulceration,  and  for  the  reflected  left  shoulder-blade 
pain.  This  is  well  shown  in  pyloric  adhesions  com- 
plicating cholelithiasis,  where,  though  the  pain  is 
originally  on  the  right  passing  to  the  right  infra- 
scapular  region,  as  soon  as  the  pylorus  becomes 
involved  in  the  inflammation  or  tied  down  by 
adhesions  the  pain  passes  also  to  the  left  sub- 
scapular region. 


CHAPTER   III 

GENERAL    DIAGNOSIS    OF     STOMACH    DIS- 
EASES,   INCLUDING    CANCER 

The  time  has  passed  in  which  the  surgeon  may- 
rest  content  to  act  on  a  diagnosis  already  made  for 
him,  leaving  with  his  medical  confreres  the  onus  in 
case  of  error ;  for  he  cannot  shirk  the  responsibility 
of  operative  interference  should  such  be  found  neces- 
sary. He  must  therefore  go  over  the  whole  of  the 
medical  evidence  and  be  prepared  to  supplement  it 
by  surgical  methods,  should  such  be  desirable  to 
elucidate  the  case. 

A  general  and  a  special  inquiry  are  necessary  in 
every  case ;  the  former  involving  the  question  of  age, 
sex,  occupation,  habits,  and  the  mental,  moral,  and 
physical  conditions,  together  with  the  history  of  the 
patient  and  the  disease  ;  the  latter  including  all  that 
can  be  ascertained  by  a  physical  examination.  AVhile 
the  general  inquiry  must  never  be  neglected;  this 
chapter  will  be  devoted  to  special  diagnostic  methods 
available  in  gastric  disease. 


DIAGNOSIS   OF    STOMACH   DISEASES    23 

Abdominal  regions. — I  luive  found  the  metliod  o£ 
artificially  dividing  tlie  abdomen  into  four  regions  by 
two  lines  passing  from  tlie  ninth  costal  cartilage  to 
the  opposite  anterior  superior  spine  to  simplify  for 
clinical  purposes  the   surgical   anatomy  of  the  abdo- 


FlG. 


men.  We  can  thus  speak  of  superior^  inferior,  right, 
and  left  abdominal  regions  as  shown  in  the  appended 
diagram. 

Inspection  slioidd  always  precede  other  diagnostic 
efforts.  The  retracted,  superior,  abdominal  region 
significant  of  starvation  from    oesophageal  stricture ; 


24  CANCER    OF   THE    STOMACH 

the  rigicl^  immobile  abdominal  wall  of  incipient  peri- 
tonitis; the  distension  of  the  abdomen  and  the  shallow 
breathing  of  general  peritonitis ;  the  sighing  respira- 
tions in  internal  haemorrhage  ;  the  irregular,  catching 
breathing  in  diaphragmatic  peritonitis  or  pleurisy 
due  to  subphrenic  inflammation ;  the  fixed  and 
bulging  ribs  in  subphrenic  abscess ;  the  tumour 
moving  with  respiration,  often  visible  in  cancer  of 
the  body  or  of  the  pyloric  end  of  the  stomach  ;  the 
enormous  bulging  of  the  upper,  or  even  of  the  whole 
abdomen  in  acute  gastric  dilatation ;  the  visible  peri- 
stalsis from  left  to  right  in  obstruction  at  the  pylorus, 
are  among  the  many  important  points  that  may  be 
revealed  by  inspection. 

Palpation  follows  inspection,  and  is  perhaps  the 
method  which  we  can  least  afford  to  omit.  The 
rigid  recti  of  perigastritis  or  incipient  peritonitis ; 
the  fixed  right  rectus  of  pyloric  or  duodenal  ulcer  ; 
the  fixed  left  rectus  of  ulcer  at  the  cardiac  end  of 
the  stomach  ;  the  tenderness  elicited  on  pressure  in 
the  superior  abdominal  region  in  all  inflammatory 
diseases  and  its  absence  in  cancer  ;  the  presence  of  a 
tumour,  its  nodular  character,  if  malignant,  and  its 
mobility  in  the  early  stages  ;  the  feeling  of  a  peri- 
staltic wave  from  left  to  right  in  mechanical  obstruction 
at  the  pylorus  ;  the  pylorus  hardening  under  the  hand 
in  pyloric  spasm,  followed  by  a  disappearance  and 
then  a  re-appearance  of  the  tumour;  the  general 
outline  of  the    dilated   stomach    to   be   felt   in    acute 


DIAGNOSIS   OF    STOMACH   DISEASES    25 

gastric  dilatation,  or  in  a  stomacli  artificially  dis- 
tended with  gas  or  air;  the  occasional  mapping  out 
of  an  hour-glass  stomach  after  artificial  distension  ;  the 
differentiation  between  communicated  and  expansile 
pulsation  in  any  tumour  suspected  to  be  aneurysm, 
and  many  other  points  can  be  almost  definitely 
settled  by  palpation.  Bimanual  palpation  with  one 
hand  in  the  loin  and  the  other  on  the  front  of  the 
abdomen  will  often  add  to  the  information  concerning 
a  tumour  or  other  associated  condition,  as,  for  instance, 
a  movable  right  kidney  dragging  on  the  pylorus, 
or  a  distended  gall-bladder  fixed  by  adhesions  to  the 
stomach. 

iS'iic'c»6'5/o?t  is  a  modification  of  palpation  frequently 
employed  to  elicit  a  stomach  splash,  which,  if  present 
habitually,  usually  indicates  pathological  dilatation, 
and  Avhich  if  present  five  to  six  hours  after  a  full 
meal  indicates  motor  inefficiency  or  some  obstruction 
at  the  pylorus,  or  both.  Leube's  method  of  palpating 
a  stomach-tube  through  the  abdominal  wall  is,  in  my 
experience,  not  of  material  value. 

In  perforating  ulcer,  the  presence  of  free  fluid  in 
the  peritoneum  may  be  ascertained  by  flicking  the 
abdomen  with  the  finger-nail  during  palpation,  when 
a  communicated  wave  may  be  felt.  The  same  method 
is  useful  in  ascertaining  the  presence  of  ascitic  fluid, 
which  if  present  along  with  a  tumour  of  the  stomach 
is  usually  indicative  of  advanced  cancer. 

The  eliciting  of  certain  tender  spots  by  palpation 


26 


CANCER   OF   THE   STOMACH 


ou  the  surface  of  the  body  may  be  of  great  assistance  ; 
for  instance,  tenderness  in  the  superior  abdominal 
region  is  suggestive  of  gastric  ulcer  and  the  site  of 
tenderness  to  the  left  or  right  is  some  guide  as  to  its 
position_,  especially  when  the   rigidity  of   the   corre- 


FiG.  3. — A.  Usual  site  of  tenderness  in  ulcer  of  stomacli. 
B.  Usual  site  of  tenderness  in  ulcer  of  pylorus,  c.  Usual 
site  of  tenderness  in  ulcer  of  duodenum. 

spending  rectus  is  taken  into  consideration.  The 
most  common  site  for  tenderness  in  ulcer  of  the 
stomach  is  at  the  point  marked  on  the  diagram 
between  the  midline  and  the  left  costal  margin ;  that 
for  ulcer  at  the  pylorus  is  usually  on  the  right  of  the 


DIAGNOSIS   OF    STOMACH   DISEASES    27 

midline^  and  that  for  ulcer  of  the  duodenum  still  more 
to  the  right  and  rather  lower.  In  the  dorsal  region 
there  are  well-marked  tender  spots  1  to  2  in.  to  the  left 
of  the  spine  opposite  the  ninth,  tenth,  and  eleventh 
ribs,  which  are  present  in  many  cases  of  ulcer. 

Percussion  is  useful  in  ascertaining  the  size  of  the 
stomach,  the  resonance  of  which,  when  not  distended 
with  food  under  normal  conditions  should  not  reach 
below  a  point  midway  between  the  ensiform  cartilage 
and  the  umbilicus,  though  stomach  resonance  reach- 
ing to  the  umbilicus  does  not  necessarily  mean  the 
dilatation  of  disease.  By  means  of  percussion  the 
size  and  shape  of  the  stomach  may  be  ascertained 
with  the  greatest  accuracy,  and  in  this  way  simple 
dilatation,  dilatation  of  the  dome  of  the  stomach  wp- 
wards,  hour-glass  deformity  and  gastroptosis  may  be 
readily  demonstrated.  It  is  more  efficiently  carried 
out  after  dilating  the  stomach,  either  Avith  air  pumped 
through  a  tube  or  by  distending  with  carbonic  acid 
gas,  either  by  giving  carbonate  of  soda  and  tartaric 
acid  in  water  in  successive  doses,  or  by  giving  a 
tumblerful  or  two  of  soda  Avater.  If  distension 
occurs  after  the  administration  of  carbonate  of  soda 
alone,  it  usually  indicates  excess  of  acid  in  the 
stomach,  which  may  point  to  hyperchlorhydria  and 
ulcer.  By  percussion  of  the  stomach  with  the  patient 
upright,  before  and  after  drinking  a  measured 
quantity  of  water,  the  size  and  capacity  of  the 
stomach   may  be   ascertained. 


28  CANCER   OF   THE   STOMACH 

In  the  diagnosis  between  a  gastric  or  a  pancreatic 
tnmonr,  light  percussion  will  reveal  resonance,  but 
deep  percussion  dulness  in  pancreatic  growth,  this 
being  more  marked  on  moderately  distending  the 
stomach   with   air. 

Percussion  is  also  of  use  in  ascertainino-  the 
presence  of  fluid  in  the  peritoneum,  whether  from 
ascites  or  from  extravasation ;  and,  in  the  diagnosis 
of  subphrenic  abscess,  by  showing  the  extent  to  which 
the  liver  is  depressed  by  the  fluid  above  it,  and  by 
revealing  a  hyper-resonant  note  above  the  liver  if 
the  abscess  contains  air  and  fluid,  this  being  changed 
to  a  note  of  dulness  when  the  patient  is  rotated  on 
to  the  affected  side- 

Auscidtation,  when  combined  with  percussion,  may 
reveal  the  splashing  sounds  in  gastric  dilatation^  and 
the  gurgling  or  metallic  sounds  in  the  cavity  of  a 
subphrenic  abscess  containing  gas ;  the  combined 
methods  are  also  of  use  in  mapping  out  the  extent  of 
gastric  dilatation. 

When  the  stethoscope  is  placed  over  the  stomach, 
and  percussion  is  made  by  tapping  a  coin  placed  on 
the  abdominal  wall  by  means  of  another  coin,  the 
area  of  gastric  resonance  may  be  readily  mapped 
out. 

In  a  healthy  person  food  occupies  about  four 
seconds  in  passing  from  the  mouth  to  the  stomach, 
but  where  there  is  stricture  of  the  oesophagus  the 
time  may  be    delayed    for   from  fourteen   to   sixteen 


DIAGNOSIS    OF    STOMACH   DISEASES    29 

seconds  ;  tliis  can  be  readily  ascertained  by  anscul- 
tating  about  three  inches  below  the  left  scapula^  at 
which  point  the  gurgle  or  amphoric  rushing  sound 
can  be  heard  when  fluid  enters  the  stomach.  This 
may  be  important  when  the  question  of  gastrostomy 
for  cancer  of  the  cardiac  orifice  or  for  stricture  of 
the   oesophagus   arises. 

Instrumental  aids  to  diagnosis. — In  case  of  pending 
starvation  from  obstruction  at  the  cardiac  orifice, 
whether  on  the  oesophageal  or  stomach  side  of  the 
sphincter,  the  question  of  gastrostomy  Avill  arise  ; 
but  it  must  first  be  made  clear  that  the  obstruction 
is  organic,  and  not  from  mere  spasm  that  might  be 
overcome  by  milder  means.  For  this  purpose  an 
oesophageal  bougie  may  be  employed,  and  if  this 
is  arrested  at  the  entrance  to  the  stomach  or  just 
before,  and  if  the  obstruction  fails  to  yield  to  gentle 
pressure  sustained  for  a  short  time,  the  stricture  is 
probably  organic,  and  if  slight  bleeding  results  from 
the  gentle  use  of  a  bougie  the  stricture  is  probably 
due  to  cancer. 

If  the  stricture  occurs  before  middle  age  it  may 
be  desirable  to  give  an  anaesthetic  before  finally 
decidiug  in  order  to  overcome  spasm  should  that  be 
the  cause  arresting  the  passage  of  a  bougie. 

Such  a  stricture  may  be  examined  directly  b}^ 
means  of  Killian's  tube  for  oesophagoscopy,  and  the 
use   of  a  forehead  light. 

Bhiagraiiliy . — The  use  of  Rontgen  rays  has   a  dis- 


30  CANCER    OF   THE    STOMACH 

tinct  role  in  certain  stomacli  cases^  especially  in  the 
diagnosis  of  the  presence  or  absence  of  metallic 
bodies  in  the  oesophagus  or  stomach.  While  the 
Mnrphy  button  was  being  used  in  gastro-enterostomy 
it  very  frequently  fell  back  into  the  stomach  and 
remained  there^  in  some  cases  setting  up  irritation  or 
ulceration.  I  have  been  consulted  in  several  such 
cases,  and  by  means  of  skiagraphy  have  been  able 
to  localise  the  foreign  body  preparatory  to  its 
removal.  I  have  also  found  skiagraphy  of  very  great 
help  where  foreign  bodies  have  been  swallow^ed  in 
ascertaining  their  position  in  the  oesophagus  or 
stomach ;  for  instance,  coins  and  dentures  are  thus 
easily  localised  both  before  and  after  entering  the 
stomach ;  and  nails,  pins,  needles,  and  suchlike 
bodies  can  be  readily  seen  in  the  stomach,  whence 
they  can  be  removed  b}^  gastrotomy. 

A  further  use  has  been  made  of  the  X  rays  to 
ascertain  the  size  of  the  stomach  and  the  situation  of 
the  pylorus  by  the  use  of  the  screen  with  the  patient 
in  the  erect  posture,  after  letting  him  sw^allow 
keratin-covered  capsules  containing  bismuth,  the 
covering  of  which  is  not  dissolved  by  the  gastric 
juice. 

Dr.  Dalton  and  Mr.  Eeid  (1)  have  made  use  of  a 
flexible  tube  containing  bismuth,  to  show^  the  outline 
of  the  stomach. 

The  digestive  powder  of  the  stomach,  an  exact 
estimate   of  which  is    essential   in    the   treatment  of 


DIAGNOSIS    OF    STOMACH   DISEASES    31 

disoi^ders  of  metabolism  and  diseases  of  the  intestine, 
has  hitherto  been  measured  by  means  of  Ewald\s  test 
breakfast,  with  the  subsequent  use  of  the  stomach- 
tube  ;  or  by  the  iodine  or  salol  reaction  of  the  urine, 
as  suggested  by  Sahli ;  or  by  estimating  the  reaction 
of  the  stomach  contents  on  coagulated  albumen  con- 
tained in  Mett^s  tubes.  Dr.  Schwarz  has  recently 
proposed  a  very  simple  method  of  examining  the 
digestive  power  of  the  gastric  juice,  at  least  so  far 
as  the  digestion  of  connective  tissue  is  concerned. 
He  uses  subnitrate  of  bismuth,  a  substance  which 
is  well  known  to  cast  a  black  shadow  when  the 
X  rays  are  directed  upon  it.  He  makes  the  patient 
swallow  a  large  pill  of  about  one  third  or  half  an 
ounce  of  the  powdered  subnitrate,  enclosed  in  an 
envelope  of  connective  tissue  obtained  from  the 
appendix  vermiformis  of  an  animal  such  as  the  sheep, 
goat,  or  ox.  If  the  abdomen  of  the  patient  is 
exposed  to  the  X  rays  a  short  time  after  swallowing 
the  pill  a  deep  black  spot  of  about  the  size  of  a 
farthino'  is  seen  at  the  bottom  of  the  stomach.  As 
soon  as  the  coating  of  connective  tissue  is  digested 
the  powder  is  scattered  and  the  contents  of  the 
stomach  are  well  mixed  with  the  powder,  after  which 
a  fainter  but  extensive  shadow,  which  gives  the 
contour  of  the  entire  organ,  is  cast  on  the  photo- 
graphic plate  or  on  the  fluorescent  screen.  This  is 
the  case  in  seven  hours  after  ingestion  of  the  pill  in 
healthy  stomachs.      If  the  digestion  is  affected,  as  is 


32  CANCER    OF   THE    STOMACH 

the  case  in  gastroptosis^  deficiency  of  acid^  pyloric 
disease  and  cancer,  the  black  spot  remains  visible 
for  a  longer  time — nine,  eleven,  or  even  twenty 
honrs.  If  the  contents  of  the  stomach  are  digested 
too  quickly,  as  in  hyperacidity,  the  black  spot  dis- 
appears in  from  two  to  five  honrs.  The  method  is 
very  simple  and  causes  no  serious  inconvenience  to 
the  patient. 

Electric  illumination  may  sometimes  be  useful  in 
demonstrating  the  size  of  the  stomach  and  in  showing 
the  position  of  a  tumour,  which  appears  as  a  dark 
patch  in  a  light  field.  It  is  easily  applied  by  letting 
the  patient  drink  sufficient  water  when  the  stomach 
is  empty  to  moderately  fill  it.  A  bougie  is  then  passed 
with  a  small  electric  lamp  near  its  extremity.  It  is 
best  used  in  the  erect  posture  and  in  a  dark  room. 

Fluorescent  media  for  transillumination  of  the 
stomach. — In  a  paper  on  dilatation  of  the  stomach  and 
gastroptosis,  R.  C.  Kemp  (2),  holding  that  trans- 
illumination of  the  stomach  is  the  ideal  method  of 
ascertaining  its  limits,  advocates  the  introduction  of 
fluorescent  media  into  the  stomach  before  the  electric 
lamp  is  passed,  by  which  means  he  has  found  that 
the  brilliancy  of  the  transillumination  is  increased 
over  one  half.  The  principal  medium  is  bisulphate 
of  quinine  in  the  strength  of  10  grains  to  1  pint  of 
water,  with,  preferably,  the  addition  of  5  minims  of 
dilute  phosphoric  acid  or  sulphuric  acid.  The 
fluorescence    is   a   pale    violet.        Increased    acidity 


DIAGNOSIS   OF  STOMACH   DISEASES    83 

intensifies  its  action,  and  fluorescence  at  once 
disappears  if  the  solution  is  rendered  alkaline.  The 
other  medium  is  fluorescing  used  by  ophthalmic 
surgeons  to  detect  ulcers  of  the  cornea.  As  is  well 
known_,  it  is  resorcin-phthalein  anhydride.  In  an 
alkaline  and  alcohol  medium  it  gives  a  green 
fluorescence.  The  hydrochloric  acid  of  the  stomach 
is  first  neutralised  by  giving  15  grains  of  sodium 
bicarbonate  dissolved  in  8  ounces  of  water ;  or  1  or  2 
ounces  of  lime  water  may  be  given  instead  and  then 
a  second  draught  consisting  of  8  ounces  of  water  in 
which  are  dissolved  15  grains  of  sodium  bicarbonate, 
1  drachm  ot"  glycerine,  and  ^  grain  to  j  grain  of 
fluorescin.  By  this  means  he  has  been  able  to 
transilluminate  the  stomachs  of  persons  with  thick 
abdominal  walls,  otherwise  a  matter  of  difficulty. 

The  removal  of  a  'portion  of  mucous  membrane 
for  microscopic  examination  by  means  of  specially 
constructed  forceps  has  been  suggested  and  even 
employed  by  certain  specialists,  but  it  need  only  be 
mentioned  to  be  condemned  as  unnecessary  and 
dangerous. 

The  exploring  syringe  may  afford  useful  aid  in 
the  diagnosis  of  sub-diaphragmatic  abscess,  and  in 
exactly  localising  its  site  as  a  preliminary  to  incision 
and  drainage. 

Gastric  lavage  may  be  employed  with  advantage 
as  a  therapeutic  measure  in  a  number  of  conditions, 
but  from  a  diagnostic  point  of  view  it   serves  a  very 

3 


34  CANCER   OF   THE    STOMACH 

useful  purpose  for  ascertaining  the  quality  of  the 
gastric  secretion  after  a  test  meal  and  the  character 
of  the  retained  stomach  contents  in  chronic  dilatation, 
also  in  estimating  the  motor  activity  of  the  stomach. 

Leube's  method  for  ascertaining  the  motor  activity 
of  the  stomach  consists  in  Avashing  out  the  stomach 
at  various  times  after  a  good  meal — a  quarter  of  a 
pound  of  freshly-minced  meat  with  some  bread. 
Within  six  hours  the  stomach  should  be  empty,  but 
in  dilatation  or  other  conditions  in  which  the  motor 
activity  of  the  wall  of  the  stomach  is  impaired  some 
food  may  be  found  many  hours  later. 

In  cases  of  dilated  stomach  where  the  succussion 
splash  is  well  marked  and  there  is  no  vomiting  it  is 
desirable  to  syphon  off  the  contents  in  order  to 
ascertain  the  presence  or  absence  of  free  HCl,  lactic 
acid,  sarcinte  or  yeast  fungi  and  other  abnormal 
contents  of  the  stomach.  The  motor  activity  of  the 
stomach  may  be  also  ascertained  by  Ewald's  test 
of  administering  salol,  which  is  not  split  up  in 
the  stomach,  but  which  breaks  up  on  coming  into 
contact  with  the  alkaline  pancreatic  juice ;  the 
salicyluric  acid  resulting  is  excreted  in  the  urine 
where  it  can  be  readily  detected  by  the  addition 
of  neutral  ferric  chloride  solution,  a  violet  coloration 
occurring. 

Fifteen  grains  of  salol  is  given  along  with  the 
food,  and  under  normal  conditions  salicyluric  acid 
appears  in  the  urine  in  from   40    to  60  minutes,  but 


DIAGNOSIS   OF    STOMACH    DISEASES    35 

in  dihitatiuu  or  other  conditions  in  wliicli  the  motor 
activity  is  impaired  the  time  is  considerably  delayed. 

Several  instruments  have  been  invented  to  test 
graphically  the  motor  activity  of  the  stomachy  which^ 
though  valuable  for  physiological  experiments^  are 
not  reliable  in  practice. 

Chemical  reactions. — In  reference  to  the  diao-nosis 

o 

of  malignant  disease  of  the  stomach  the  relative 
abundance  or  absence  of  free  HCl  has  been  pointed 
out  by  Ewald  as  being  of  importance.  In  order  to 
determine  its  existence  the  patient  should  take  a  test 
breakfast  consisting  of  a  cup  of  weak  tea  and  a  little 
dry  toast.  An  hour  later  the  stomach  tube  should 
be  passed^  and  the  contents  of  the  stomach  drawn 
off.  These  are  to  be  tested  by  Gunsberg^s  test  for 
free  HCL  The  reagent  consists  of  2  parts  of 
phloroglucin  and  1  part  of  vanillin  in  30  parts  by 
weight  of  absolute  alcohol.  When  a  few  drops  of 
the  filtered  contents  of  the  stomach  are  evaporated 
to  dryness  in  a  porcelain  dish  with  an  equal  quantity 
of  the  reagenl_,  if  free  HCl  be  present_,  red  cr^'stals 
will  form ;  should  there  be  much  peptone  present_,  no 
crystals,  but  a  red  paste  will  result. 

The  absence  or  deficiency  of  free  HCl  occurs  in 
several  morbid  states,  but  its  presence  is  a  strong- 
point  against  a  diagnosis  of  malignant  disease  of  the 
stomach.  Hyperacidity,  on  the  other  hand,  is  as 
characteristic  of  ulcer  as  diminished  acidity  is  of 
cancer. 


36  CANCER   OF   THE    STOMACH 

The  mere  presence  of  an  acid  reaction  should  not 
be  held  as  proving  the  presence  of  free  HCl  since 
this  may  be  caused  by  acid  salts  or  by  free  organic 
acids.  Of  these  latter  the  most  imjDortant  is  lactic 
acid,  and  it  the  practitioner  should  be  able  to  recog- 
nise, since  its  presence  in  appreciable  quantity  in  the 
later  stages  of  digestion  is  of  considerable  import, 
implying  as  it  does  that  excessive  fermentation  is 
going  on  in  the  stomach.  It  can  be  readily 
recognised  by  the  use  of  Uffelmann^s  reagent,  which 
can  be  made  by  adding  1  drop  of  liq.  ferri 
perchlor.  to  1  ounce  of  a  1  per  cent,  solution  of  car- 
bolic acid.  This  will  give  an  amethyst  blue  solution, 
the  colour  of  which  is  changed  to  yellow  on  the 
addition  of  the  merest  trace  of  lactic  acid.  Since 
inorganic  acids  decolourise  Uffelmann's  reagent, 
w^hile  sugar,  alcohol  and  phosphates  give  the  same 
reaction  with  it  as  lactic  acid,  it  is  necessary  to 
extract  the  lactic  acid  by  shaking  the  filtrate  left 
after  filtering  a  small  quantit}^  of  gastric  contents 
with  ether,  to  allow  the  ether  to  separate  from 
the  watery  solution,  and  after  decanting  it  to 
evaporate  the  ethereal  solution  until  only  a  few 
drops  remain.  If  any  free  lactic  acid  be  present, 
on  adding  some  of  this  to  Ufi^elmann's  reagent  the 
alteration  in  colour  noted  above  will  take  place. 
The  fatty  acids,  especially  butyric  acid,  give  a 
somewhat  similar  reaction,  but  only  when  present 
in  larger  projDortions   than  they   are   found   to  occur 


DIAGNOSIS   OF    STOMACH   DISEASES    37 

in  the  stomach.  The  presence  of  lactic  acid  and  the 
absence  of  free  HCl  are  strongly  suggestive  of 
cancer. 

Osier  (3)  states  that  in  84  cases  of  cancer  of  the 
stomach  out  of  9-i  examined  free  HCl  was  absent. 

Examination  of  vomited  matters. — With  regard  to 
vomit,  the  first  thing  to  consider  is  the  quantity 
vomited  at  one  time.  Nurses  should  be  trained  to 
estimate  this  carefully  and  also  to  preserve  specimens 
on  all  occasions.  In  dilated  stomach  vomitino- 
usually  does  not  occur  more  than  once  daily^  some- 
times only  every  second  or  third  day,  and  the 
quantity  at  any  time  is  correspondingly  large. 

In  ulcer  of  the  stomach  a  considerable  portion  of 
the  last  meal  may  be  brought  up  within  an  hour  or 
two  of  its  ingestion,  and  the  pain  it  has  caused  be 
thereby  relieved. 

The  smell  should  be  considered,  a  yeasty  smell 
being  characteristic  of  dilation  of  the  stomach,  a 
habitually  foetid  odour  of  cancer  of  the  stomach, 
and  a  feculent  odour  of  intestinal    obstruction. 

Vomit  is  usually  acid  in  reaction  ;  but  it  may  be 
alkaline  in  some  cases  of  chronic  dyspepsia,  or  when 
there  is  much  blood  present. 

The  most  important  abnormal  constituent  of  vomit 
is  blood.  In  large  quantities  its  nature  is  obvious, 
and  the  event  is  suggestive  of  simple  ulcer ;  but  in 
cirrhosis  of  the  liver  profuse  haematemesis  may 
occur    owing    to     rupture     of     dilated     veins.        In 


38  CANCER    OF   THE    STOMACH 

smaller  quantities  the  vomit  lias  a  cliaracteristic 
dark  appearance^  resembling  coffee  grounds,  and 
tliis  may  be  due  to  cancer  or  simple  ulcer.  When 
the  existence  of  blood  in  vomited  matter  is  doubtful, 
the  most  reliable  guide  is  the  ha3min  test,  which 
may  be  done  in  the  following  manner  :  evaporate 
a  small  cpiantity  of  the  gastric  contents  to  dryness, 
powder  the  residue  and  place  some  along  with  a 
cr3\stal  of  common  salt  on  a  microscopic  slide,  add 
a  drop  of  glacial  acetic  acid  and  boil  over  a  spirit 
lamp,  cover  with  a  cover  glass  and  examine  under 
a  high  power  for  the  small,  dark-brown  crj'stals  of 
haemin.  As  a  rule  it  is  not  necessary  to  add  sodium 
chloride,  since  fresh  blood  contains  sufficient  of  it  ; 
but  since  excess  of  the  salt  does  not  interfere  with  the 
reaction  it  is  well  to  use  a  cr3'stal  or  two. 

In  cancer  of  the  stomach  blood  is  frequently  pre- 
sent in  the  vomit,  often  in  small,  sometimes  in  con- 
siderable, only  rarely  in  large  quantity. 

Pus  is  sometimes,  but  not  often  vomited.  In 
considering  both  pus  and  blood  in  a  fluid  said  to 
have  been  vomited,  it  must  be  rememl:)ered  that 
when  large  quantities  of  fluid  are  expelled  from  the 
lungs — e.  g.  on  the  rupture  of  an  empyema  into  the 
lung,  or  a  profuse  ha}moptysis — the  sensation  to  the 
patient  is  often  as  if  vomiting  had  occurred.  The 
presence  of  food  and  the  general  absence  of  frothi- 
ness  will  help  to  distinguish  true  vomit,  while 
vojnited  l)lood  is    o-enerallv  much  darker    than  blood 


DIAGNOSIS    OF    STOMACH   DISEASES    39 

from  the  lungs.  But  the  only  reliable  way  to 
make  a  distinction  is  to  inquire  carefully  into  the 
facts  of  the  occurrence.  Pus  in  the  vomit  may 
arise  from  an  empyema  of  the  gall-bladder,  or  a 
pancreatic  or  other  abscess  bursting  into  the 
stomach  or  oesophagus. 

Examination  by  the  microscope  of  vomited  material 
is  usually  of  secondary  importance,  but  it  sometimes 
affords  great  assistance,  as  in  the  case  of  a  subdia- 
phragmatic  abscess  under  my  care  bursting  into  the 
lung,  where  the  presence  of  half- digested  muscular 
fibres  and  the  absence  of  elastic  tissue  distinctly 
proved  the  source  of  the  pus  to  be  from  the  stomach 
and  not  from  an  abscess  of  the  lung  or  an  empyema ; 
and  in  some  cases  of  cancer  Avhere  portions  of 
growths  or  groups  of  cells  are  occasionally  obtained 
by  means  of  lavage.  In  dilatation  of  the  stomach 
the  sarcina  ventriculi  is  frequently  to  be  seen  to- 
gether with  yeast  cells.  In  cancer,  where  macros- 
copically  there  is  no  evidence  of  blood,  red  blood- 
corpuscles  may  often  be  found  on  microscopic 
examination. 

An  examination  of  the  faeces  is  said  to  show  the 
presence  of  blood  by  chemical  tests  almost  constantly 
when  there  is  cancer  of  the  stomach,  but  only  occa- 
sionally in  case  of  ulcer.  My  personal  experience 
of  this  diagnostic  sign  is  not  sufficiently  extensive 
for  me  to  speak  positively  as  to  its  value,  though  I 
have  found  it  of  use  in  some  cases. 


40  CANCER   OF   THE    STOMACH 

An  examination  of  the  urine  for  nitrogen  is  said 
to  be  of  use  in  tlie  diagnosis  of  cancer^  as  in  every 
case  of  malignant  disease  it  is  said  to  be  consider- 
ably reduced  from  the  normal. 

A  diagnosis  of  the  position  of  a  gastric  tumour 
has  been  claimed  by  Glaessner  by  means  of  an 
examination  of  the  stomach  contents. 

Having  determined  that  the  gastric  mucous 
membrane  can  be  divided  into  two  physiologicall}^ 
distinct  segments^  the  fundus,  which  has  a  large 
supply  of  glands_,  and  the  pylorus,  which  has  but 
few  glands,  Iv.  Glaessner  (4)  describes  how  the  locali- 
sation of  tumours  can  be  made.  Pepsin  and  rennet 
are  both  produced  by  the  mucosa  of  the  fundus,  but 
only  pepsin  and  no  rennet  is  secreted  by  that  of  the 
pylorus.  It  therefore  occurred  to  Glaessner  that  if 
one  examined  the  contents  of  the  stomach  after  a 
trial  meal  in  case  of  gastric  tumour  one  might  be 
able  to  learn  more  of  the  situation  of  the  growth. 
In  the  cases  in  which  he  was  able  to  test  this  he 
estimated  the  total  acidity  by  means  of  plienol- 
phthaleine  HCl  by  Toepfer's  reagent,  pepsin  by 
Mett^s  method,  and  rennet  by  its  direct  action  on 
milk,  within  a  given  time.  He  considers  that 
normally  the  pepsin  should  be  present  at  5  mil- 
limetres— that  is,  that  10  cubic  centimetres  of 
normal  gastric  juice  should  be  able  to  completely 
digest  a  column  of  albumen  in  Mett\s  test  tube 
measuring    5    millimetres     in     twenty-four     hours ; 


DIAGNOSIS   OF    STOMACH    DISEASES    41 

and  that  rennet  should  have  the  value  of  1  in 
100,  that  is  J  that  O'l  cubic  centimetre  of  normal 
neutralised  iuice  should  be  able  to  coaorulate  10 
cubic  centimetres  of  milk  at  30°  to  40°  0.  within 
half-an-hour.  In  six  cases  of  carcinoma  of  the 
pylorus,  confirmed  at  the  operation  or  at  the 
necropsy,  the  pepsin  was  between  1  and  3  milli- 
metres, while  the  rennet  was  normal.  In  seven 
cases  of  carcinoma  of  the  fundus  he  found  that  not 
only  was  the  pepsin  much  diminished,  as  in  the 
pyloric  cases,  but  the  rennet  also  was  diminished, 
or  was  entirely  absent.  He  looks  upon  this  method 
of  diagnosis  as  highly  valuable. 

Examination  of  the  blood. — The  blood,  as  a  rule, 
shows  the  changes  found  in  secondary  anaemia. 
Beyond  this  the  information  given  by  an  examina- 
tion  is  of  doubtful   value. 

Krokiewicz  states  that  there  is  no  change  in  the 
red  blood-corpuscles.  In  thirteen  cases  digestion 
leucocytosis  was  absent.  Krokiewicz  agrees  with 
Lowitt  that  this  sign  is  "  of  equal  value  with  the 
absence  of  HCl  and  the  jDresence  of  lactic  acid." 
In  nearly  all  cases  the  alkalinity  of  the  blood  was 
lessened.      Osier  and  Macrae  come  to  the  followino* 

o 

conclusions  : 

(1)  Neither  an  increase  of  the  leucocytes  nor 
special  variations  in  the  forms  appear  to  be  of  u^ny 
moment  in  the  diao-nosis  of  cancer  of  the  stomach. 

(2)  The  presence  or  absence  of   digestion  leucocy- 


42  CANCER    OF    THE    STOMACH 

tosis  is  too  uncertain  to  be  of  much  assistance  in 
diagnosis  (in  twenty-two  cases  it  was  present  in  ten, 
absent  in  twelve). 

According  to  Lindner  and  Kuttner  absence  of  diges- 
tion leucocytosis  is  noticed  rather  more  frequently  in 
malignant  than  in  simple  disease.  Hartmann  and 
Silhol  (5)  have  recently  communicated  to  the  Societe 
de  Chirnrgie  the  results  of  some  researches  made 
on  the  blood  of  surgical  patients.  In  the  course  of 
these  researches  they  have  become  convinced  that 
in  cancer  of  the  stomach  an  examination  of  the  blood 
is  more  likely  to  prove  useful  than  a  chemical 
investigation  of  the  gastric  contents.  The  authors 
made  particular  investigation  on  two  questions  : 

[a)  The  degree  of  an^Bmia  characterised  by  dimi- 
nution of  the  quantity  of  haemoglobin,  which  may 
depend  on  the  reduction  of  the  number  of  globules 
or  on  the  reduced  proportion  of  haemoglobin  in  their 
contents. 

(h)  The  existence  of  leucocytosis.  The  presence 
of  cancer  of  the  stomach,  it  is  held,  is  indicated  by 
a  well-marked  association  of  decided  anaemia  with 
decided  leucocytosis.  Antemia  is  marked  less  b}' 
the  diminished  number  of  globules  than  by  (1)  a 
diminished  proportion  of  the  hDemoglobin  in  the 
globules  ;  (2)  by  irregularity  in  the  form  of  the 
globules,  indicating  a  profound  modification  of  the 
elasticity  and  texture  of  the  red  globules;  and  (3) 
by  inequality  in    the  size  of  those  globules  that  are 


DIAGNOSIS    OF    STOMACH   DISEASES    43 

not  misshapen.  The  leucocytosis,  to  have  sltij  value 
as  a  symptomatic  sign,  should  be  very  marked,  and 
should  affect  especially  the  non-nucleated  cells. 

REFERENCES. 

1.  Dalton  and  Reid.— Clin.  Soc  Trans.,  1905,  p.  122. 

2.  Kemp,  R.  C.—Med.  News,  New  York,  August  Cth,  1904;    and 

Brit.  Med.  Jonrn.,  Supplement. 

3.  Osier. — Principles  and  Practice  of  Medicine,  3rd  edit.,  p.  491. 

4.  Glaessner,  K.— Berlin.  Uin.  Woch.,  July  21st,  1902. 

5.  Hartmann  and  Silhol. — Eev.  de  Chir.,  1901,  No.  2. 


CHAPTER    lY 

CANCER  OF  THE  STOMACH 

Primary  cancer  of  the  stomacli  may  be  of  the 
cylindrical  or  spheroidal^  very  rarely  of  the  squamous 
t3^pe  (Rolleston^  Jonrn.  Patliology  and  Bacteriology, 
August,   1905). 

If  the  stroma  be  abundant  the  term  "  scirrhus  or 
hard  cancer  ^^  is  applied,  and  if  the  stroma  be  scant}^ 
the  cancer  is  spoken  of  as  "  medullary  "  ;  moreover, 
either  may  take  on  a  colloid  form. 

Fenwick,  out  of  115  cases,  found  63"3  per  cent,  of 
the  spheroidal  type,  28*6  per  cent,  of  the  cylindrical 
type  and  7'8  per  cent,  in  which  the  growth  was 
undero'oino*  colloid  deo-eneration. 

Of  41  cases  of  spheroidal-celled  carcinomata  22 
were  of  the  soft  or  medullary  and  19  of  the  scirrhous 
variety. 

Such  diiferences  in  classification  and  relative 
percentages  in  each  class  are  found  in  writings  on 
this  subject  that  statistics  as  to  relative  frequencies 
of  the  different  varieties  would  seem  to  have  little 
value ;     moreover,      there     are     so     many    tumours 


CANCER    OF   THE    STOMACH  45 

occupying  intermediate  positions  between  tlie  various 
classes  that  accurate  classification  is  really  difficult. 

With  regard  to  ulceration^  metastasis  and  secondary 
growths,  there  is  no  striking  difference  between  the 
two  chief  varieties  of  the  disease. 

Secondary  carcinoma  of  the  stomach  is  not  very 
common  and  is  unimportant  from  a  clinical  stand- 
point, as  surgical  treatment  is  contra-indicated  in 
all  such  cases.  Welch  collected  37  cases  of  which 
17  were  secondary  to  mammary  cancer,  8  to  cancer 
of  the  oesophagus,  3  to  cancer  of  the  mouth  and  nose, 
and  9  to  cancer  in  other  parts  of  the  body. 

An  analysis  of  1796  cases  compiled  from  various 
authors  showed  the  pylorus  to  be  affected  in  1110, 
the  lesser  curvature  in  197,  the  cardiac  orifice  in  158, 
and  the  rest  of  the  stomach  in  331  (Furnival). 

Dissemination  of  cancer  usually  occurs  through 
the  lymphatics,  but  growth  in  cancer  of  the  stomach 
may  be  disseminated  by  the  blood-vessels,  especially 
the  portal  vein.  Extension  may  also  occur  through 
adhesions  or  by  direct  implantation  on  a  neighbouring 
surface  through  contact. 

Extension  through  the  lymphatics. — To  Cuneo  in 
his  masterly  thesis  the  profession  is  indebted  for  the 
excellent  description  of  the  lymphatic  system  of  the 
stomach,  which  is  well  shown  in  the  diagram  taken 
from  his  work  (p.  19).  The  lymphatics,  as  will  be 
seen,  drain  into  the  glands  along  the  lesser  curvature 
as   well    as  into  those   along    the  greater  curvature, 


46  CANCER   OF    THE    STOMACH 

especially  towards  the  pyloric  end  of  the  stomach 
and  in  the  adjoining  portion  of  the  great  omentum  ; 
thence  the  lymph  passes  through  the  coeliac  glands  on 
its  way  to  the  thoracic  duct,  which  transmits  it  to  the 
general  circulation  by  way  of  the  left  subclavian  vein. 

On  reaching  the  heart  the  lymph  passes  through 
the  pulmonary  circulation,  and  infective  particles 
may  be  arrested  in  the  lungs,  or  if  passing  onwards 
into  the  greater  circulation  they  may  be  disseminated 
as  emboli  and  lodge  in  any  part  of  the  body,  in  this 
way  even  passing  back  to  the  abdominal  viscera. 

When  the  pylorus  is  affected,  extension  takes 
place  rapidly  along  the  lesser  curvature  ;  the 
lymphatics  and  the  adjoining  glands  becoming 
involved  as  far  as  the  point  where  the  coronary 
artery  joins  the  stomach,  at  Avliich  place  the  lymph- 
channels  pass  from  the  lesser  curvature.  The  reason 
of  almost  constant  extension  in  this  direction  is  that 
this  is  the  chief  course  along  which  the  lymph 
stream  travels  from  the  stomach. 

In  consequence  of  this  early  extension  a  mere 
excision  of  the  pylorus  alone  for  cancer  is,  as  a  rule, 
almost  useless,  since  to  get  beyond  the  disease  it  is 
necessary  to  remove  a  considerable  portion  of  the 
lesser  curvature  with  its  adherent  lymph-vessels  and 
glands. 

The  lymph-nodes  on  the  greater  curvature  do  not 
usually  extend  further  to  the  left  than  a  point  near 
the  middle. 


CANCER   OF   THE    STOMACH  47 

The  dome  of  the  stomach  is  almost  devoid  of 
l^anph-vessels,  hence  in  extensive  gastrectomy  this 
part  of  the  organ  can  frequently  be  safely  left  to 
form  part  of  the  future  stomach. 

Mr.  J.  F.  Dobson^  in  his  Arrib-  and  Gale  Lectures^ 
February,  1907,  showed  the  presence  of  a  gland  on 
the  left  of  the  oesophagus,  and  said  that  there  were 
usually  one  or  two  lymph-nodes  in  the  gastro-splenic 
omentum. 

Cuneo  observed  that  pyloric  growth  frequently 
spares  the  duodenum,  hence  when  a  tumour  ex- 
tends well  into  it  from  the  pylorus  the  chances  are 
that  it  may  be  inflammatory  swelling  around  an 
ulcer.  This  fact  has  on  several  occasions  enabled 
me  to  rest  satisfied  Avith  a  gastro-enterostomy  when 
otherwise  I  should  have  performed  a  partial  gas- 
trectomy. The  rule  is,  however,  not  absolute,  as  I 
have  seen  both  cancer  and  sarcoma  extend  through 
the  pylorus  into  the  duodenum. 

Extension  by  continuity. — Cancer  always  extends 
beyond  the  area  of  induration,  for  while  the  limit  of 
induration  may  be  the  diseased  mucosa,  the  sub- 
mucosa  may  be  involved  in  growth  for  some  distance 
beyond,  and  only  scattered  groups  of  cells  yielding- 
no  evidence  to  the  touch  can  be  discovered  on 
microscopic  examination.  It  follows,  therefore,  that 
any  effort  at  extirpation  must  go  fully  an  inch 
beyond  the  margins  of  the  tumour.  It  is  specially 
important  that  the  removal    should   be  wide  of   the 


48  CANCER   OF   THE    STOMACH 

disease  on  the  cardiac  side  of  tlie  tumour^  and  that 
the  lymphatic  area  along  the  lesser  curvature  should 
be  removed. 

Extension  through  adhesions. — In  a  very  large  pro- 
portion of  cases  adhesions  are  found  at  the  time  of 
operation  between  a  cancerous  tumour  of  the 
stomach  and  adjoining  organs^  especially  the 
pancreas^  liver  and  biliary  passages.  This  not 
only  adds  to  the  difficulty  of  the  operation  but 
also  tends  to  invasion  of  the  neighbouring  organs 
by  continuity.  These  adhesions  are  due  either  to 
local  inflammation  set  up  by  the  growth  or  to 
extension  of  the  malignant  neoplasm. 

Gussenbauer  and  Winiwarter  state  that  adhesions 
are  found  in  63  per  cent,  of  cases  of  pyloric  cancer^ 
a  statement  which  my  personal  experience  on  the 
operating  table  would  lead  me  to  believe  is  even 
below  the  mark. 

Extension  through  the  blood-vessels  is  much  com- 
moner in  sarcoma  than  in  cancer  of  the  stomachy  but 
there  are  many  examples  of  metastasis  to  the  lungs, 
brain  and  other  organs  in  true  gastric  carcinoma  that 
can  only  be  accounted  for  by  vascular  extension.  Ex- 
tension by  way  of  the  portal  vein  to  the  liver  is  the 
best  example  of  vascular  diffusion  of  cancer,  but  if 
infective  particles  pass  through  the  portal  meshwork 
in  the  liver  they  may  be  diffused  by  the  general 
circulation  to  any  part  of  the  body. 

Extension  thi'ough  contact  is  seen  when  the  abdo- 


CANCER   OF    THE   STOMACH  49 

minal  wall  opposite  to  a  fungating  growth  in  tlie 
stomacli  becomes  involved  and  when  the  various 
tissues  and  organs  forming  the  stomach  bed  be- 
come invaded  without  there  being  any  direct 
channel  either  through  the  lymphatics  or  blood- 
vessels to  account  for  the  extension. 

Although  secondary  cancer  of  the  stomach  may 
occur  subsequent  to  cancer  of  the  oesophagus,  breast, 
gall-bladder,  intestine  and  other  organs,  it  is  not  of 
importance  from  a  surgical  standpoint. 

Cancer  incidence. — Age. — Cancer  of  the  stomach 
may  occur  at  any  period  of  life,  from  early  infancy 
up  to  extreme  old  age,  but  it  is  most  frequently  met 
with  from  forty  to  seventy.  In  the  census  reports 
for  1890  the  death  rate  from  cancer  of  the  stomach 
was  10-24  per  100,000  living  in  the  registration 
area.  On  analysis  this  yielded  3*22  between  the 
ages  of  fifteen  and  forty-five ;  34*45  between  forty- 
five  and  sixty-five,  and  79*96  over  sixty-five  years 
(Osier   and    Macrae,  Cancer    of  the    Stomach,  p.  G). 

I  have  operated  for  cancer  of  the  pylorus  at  the  early 
age  of  21,  and  for  cancer  of  the  colon  at  the  age  of  14. 

Race. — The  white  races  seem  more  predisposed  to 
cancer  than  the  black  ;  Osier  gives  the  actual  inci- 
dence as  6  whites  to  1  coloured. 

Sex. — The  various  estimates  of  the  relative  fre- 
quency of  cancer  of  the  stomach  in  the  two  sexes 
enables  one  to  say  that  it  is  decidedly  more  frequent 
in  males  than  females.      Osier  gives  it  as   5*2  to  1  ; 

4 


50  CANCEE    OF   THE    STOMACH 

Brinton  2  to  1  ;  Reiche  TS  to  1  ;  my  own  experience 
in  110  operations  on  the  stomacli  for  cancer  lias 
differed  considerably  in  hospital  and  private.  Of 
55  hospital  patients  30  were  males  and  25  females  : 
1*2  males  to  1  female.  Of  54  private  patients  44 
were  male  to  10  female  ;   4*4  males  to  1  female. 

Pre-canceroiis  conditions. — The  so-called  pre-can- 
cerons  stage  of  malignant  disease  may  be  dne  to  dis- 
tnrbances  of  nntrition,  to  previons  injnry^  to  congenital 
defect,  or  to  other  departnres  from  the  normal  condi- 
tions. Senility  and  decadence  of  tissues  which  have 
passed  the  period  of  their  usefulness  and  are  about  to 
undergo  physiological  rest  are  predisposing  factors. 
Predisposing  conditions  also  exist  in  certain  parts  of 
the  body  where  embryological  vestiges  or  rests  are 
found,  and  in  certain  regions,  as  the  pylorus  and  the 
caecum,  and  at  the  lines  of  junction  of  skin  and 
mucous    membrane.  In     certain     situations    pre- 

cancerous conditions  can  be  readily  recognised  ; 
this  especially  applies  to  the  tongue,  lips,  larynx, 
uterus,  and  the  skin,  suggesting  strongly  that  cancer 
is  a  new  implantation  on  a  prepared  ground  ;  probably, 
if  we  could  only  find  it,  ever}^  cancer,  whether 
external  or  internal,  follows  on  a  pre-cancerous  con- 
dition, such  as  cancer  of  the  gall-bladder  on  ulcera- 
tion produced  by  gall-stones,  cancer  of  the  stomach 
on  chronic  gastric  ulcer,  epithelioma  of  the  penis 
on  irritation  under  a  phimosis,  cancer  of  the  bladder 
on  papilloma  or  on  ulcers  due  to  calculi,  and  cancer 


CANCER   OF   THE    STOMACH  51 

of  tlie  rectum  and  colon  on  stercoral  or  other  ulcers. 
The  liability  of  benign  tumours,  especially  on  epithe- 
lial surfaces,  to  undergo  malignant  changes  is  well 
recognised,  hence  the  removal  of  such  is  generally 
advisable. 

A  general  acceptance  of  the  view  that  cancer  has 
usually  a  pre-cancerous  stage,  and  that  this  stage  is 
one  in  which  operation  ought  to  be  performed,  would 
be  the  means  of  saving  many  useful  lives,  for  it 
would  lead  to  the  removal  of  all  suspicious  epithelial 
conditions  before  the  onset  of  cancer. 

I  hold  that  the  arrest  or  removal  of  known  causes 
as  well  as  the  abolition  of  discoverable  pre-cancerous 
conditions,  whenever  or  however  occurring*,  constitute 
true  preventive  treatment. 

Pre-cancerous  conditions  of  the  stomach  are  in 
certain  cases  distinctly  recognisable,  and  if  diagnosed 
and  treated  might  save  many  patients  from  carcinoma. 
As  the  stomach  is  one  of  the  commonest  sites  of 
cancer,  if  even  a  percentage  of  cases  can  be  saved 
from  malignant  disease  by  timely  treatment  a  great 
advantage  will  have  been  gained. 

Ulcus  carcinomatosum. — The  question  of  the  can- 
cerous transformation  of  an  ulcer  of  the  stomach  was 
first  discussed  by  Cruveilhier  in  1839.  Rokitansky, 
in  1840,  also  recognised  the  difference  between 
chronic  ulcer  and  cancer,  and  said  that  the  latter 
might  be  implanted  upon  the  former.  To  Dittrich, 
writing  in   1848,  belongs  the  chief  credit  of  drawing 


52  CANCER   OF   THE   STOMACH 

attention  to  tlie  subject.  He  described  in  160  cases 
of  new  growth  six  cases  of  cancer  developing  in  the 
immediate  vicinity  of  active  or  healed  ulcers,  two 
cases  of  the  association  of  cancer  and  ulcer,  and  two 
cases  in  which  the  cancer  was  limited  to  a  certain 
part  of  the  margin  of  the  ulcer,  the  rest  remaining 
sound.  Brinton,  in  1856,  recognised  the  possibility 
of  the  grafting"  of  cancer  upon  long-standing  ulcer. 

Lebert,  in  1878,  considered  that  the  cancerous 
transformation  occurred  in  9  per  cent,  of  ulcers ;  but 
Zenker,  in  1882,  expressed  a  strong  opinion  that  all 
cases  of  cancer  of  the  stomach  were  secondary  to 
ulceration. 

He  attributed  the  cancerous  degeneration  in  an 
ulcer  to  glandular  changes  caused  by  inflammation 
and  cicatrisation  exciting  and  favouring  ej^ithelial 
proliferation.  He  called  attention  for  the  first  time 
to  the  persistence  of  free  hydrochloric  acid  in  the 
stomach  contents  in  cases  of  cancer  grafted  upon  ulcer. 
In  1889  Rosenheim  found  in  forty- six  cases  of  cancer, 
four  in  which  the  malignant  change  was  secondary 
to  ulceration.      In  all  these,  free  HCl  was  present. 

G.  Fuetterer,  in  1902,  made  an  extensive  research 
into  the  question  of  the  origin  of  carcinoma  of  the 
stomach  from  chronic  round  ulcer.  His  conclusions, 
briefly  stated,  were  as  follows  : 

(1)  If  a  carcinoma  develops  from  a  chronic  ulcer 
of  the  stomach  then  this  development  occurs  from 
those  parts  of  the  edges  of  the  ulcer  which  are  most 


PLATE    II. 


Cancer  of  anterior  Avail  of  the  stoinacli  producing-  hour-o-lass  contraction. 

Man,  aged  sixty,  with  four  years'  history  of  vomitint,^  and  other  signs 
of  ulcer.  This  is  an  example  of  "  ulcus  carcinoniatosum."  (No.  2408c, 
Royal  College  of  Surgeons'  Museum.) 


To  fa 


Aill^n-d  cf-  So>i,  Tmpr. 


CANCER   OF   THE   STOMACH  53 

exposed  to  mecliaiiical   irritation    by  tlie  contents  of 
the  stomach. 

(2)  In  the  pyloric  region  it  is  the  lower  pyloric 
margin  of  the  ulcer  which  is  most  exposed  to 
mechanical  irritation^  and  from  which  carcinoma 
develops.  But  other  parts  of  the  edges  may  be  the 
ones  involved  when  dilatation  and  adhesions  have 
changed  the  position  of  the  organ. 

(3)  Development  of  carcinoma  from  ulcers  of  the 
stomach  in  the  pyloric  region  occurs  with  great  fre- 
quency, while  such  a  development  occurs  less  often  in 
other  parts  of  the  stomach. 

In  1903  Audistere  recorded  examples  and  made 
very  careful  examination  of  four  personal  cases. 
His  conclusions  are  summed  up  in  the  following 
manner  : 

(1)  Simple  ulcer  of  the  stomach  may  be  the 
starting-point  o^  a  cancerous  growtli,  a  condition  of 
things  which  appears  to  be  not  infrequent. 

(2)  This  malignant  degeneration  affects,  as  a  rule, 
the  chronic  ulcers,  especially  in  the  pre-pyloric  region. 
The  change  begins  in  the  mucous  membrane  at  the 
margin  of  the  ulcer. 

(3)  The  transformed  ulcer  presents  for  a  long 
time  almost  the  same  symptoms  as  a  simple  ulcer, 
but  the  diagnosis  may  be  made  by  noting  the  resist- 
ance to  treatment,  the  wasting,  the  persistence  of  the 
symptoms,  and  the  progressive  anaemia.  The  pain, 
as  a  rule,  is  more  severe  than  in  cases  of  simple  ulcer. 


54  CANCER   OF   THE    STOMACH 

(4)  In  cases  of  cancer,  apparently  primary,  the 
origin  in  an  ulcer  may  be  suspected  if  tlie  pain  is 
unusually  severe  and  paroxysmal,  if  liyperclilorliydria 
is  pronounced,  or  if  liasmatemesis  or  perforation 
occurs.  The  prognosis  is  decidedly  more  grave,  for 
the  progress  of  cancer  grafted  upon  ulcer  is  more 
rapid  and  bleeding  or  perforation  is  liable  to  occur. 

If  these  conclusions  are  correct,  and  my  expe- 
rience tells  me  they  are,  then  it  is  quite  clear 
that  we  must  in  all  cases  in  which  an  ulcer  of  the 
stomach  resists  treatment,  or  its  scar  narrows  the 
pylorus,  recommend  an  early  gastro-enterostomy  or 
excision  of  the  ulcer,  in  order  to  prevent  the  deve- 
lopment of  carcinoma.  If  a  gastro-enterostoni}^  has 
been  performed,  then  the  mechanical  irritation  by 
food  of  the  ulcer  in  the  pyloric  region  is  reduced, 
and  the  friction  necessary  to  produce  a  carcinoma 
will  probably  not  occur.  The  estimates  of  the  fre- 
quency of  this  malignant  implantation  upon  a  chronic 
ulcer  vary  greatly.  The  number  of  carcinomata 
beginning  in  chronic  ulcer  is  reckoned  at  3  per  cent, 
by  Fenwick,  Flange  and  Berthold,  4  per  cent,  by 
Wollmans,  G  per  cent,  by  Rosenheim  and  Hauser,  9 
per  cent,  by  Leber t,  and  14  per  cent,  by  Sonicksen. 
Zenker,  as  alread}^  mentioned,  believes  that  all,  or 
almost  all  carcinomata  are  secondary  to  ulcer.  Mayo, 
in  157  cases  of  cancer  of  the  stomach,  found  a  previous 
history  of  ulcer  in  60  per  cent.  In  no  less  than  59'3 
per  cent,  of  cases  of  cancer  of  the  stomach  on  which 


CANCER   OF   THE    STOMACH  55 

I  have  performed  gastro-entcrostomy  for  the  relief  of 
symptoms^  the  disease  having  advanced  too  far  for  gas- 
trectomy, the  long  history  of  painful  dyspepsia  sug- 
gested the  possibility  of  ulcer  preceding  the  onset  of 
malignant  disease. 

The  origin  of  carcinoma  in  an  ulcer  of  the  stomach  is 
only  another  instance  added  to  many  of  which  we  have 
knowledge_,of  the  effect  of  persisting  irritation  inestab- 
lishing  malignant  changes.  Carcinoma  occurs  most 
frequently  in  those  areas  in  which  the  ulcers  chiefly  lie. 
Whatever  the  frequency  of  the  malignant  change  in 
chronic  ulcer  may  prove  to  be,  the  fact  of  its  occur- 
rence should  be  an  additional  incentive  to  the  earlier 
surgical  treatment  of  ulcers  which  prove  rebellious. 

Symptoms. — Since  cancer  "j^er  se^'  has  no  sym- 
ptoms, it  not  infrequently  happens  that  if  the  growth 
involves  the  body  of  the  stomach  and  not  the  ori- 
fices, it  may  pursue  its  complete  course  without 
giving  rise  to  any  definite  local  symptoms,  and  it 
has  happened  that  the  cause  has  only  been  dis- 
covered at  autopsy.  This  form  of  latent  cancer 
contributes  5  per  cent,  of  all  cases  according  to 
Professor  Osier,  Avho  also  gives  it  as  his  opinion  that 
10  per  cent,  of  all  cases  of  cancer  of  the  stomach  run 
an  extremely  rapid  course,  terminating  in  death 
within  three  months. 

Dr.  Newton  Pitt  (4)  drew  attention  to  seventeen 
obscure  gastric  cancer  cases  that  had  occurred  in 
Guy^s  Hospital,  in  which  the  main  symptoms  had  been 


G 

roup 

A. 

}} 

B. 

}} 

C. 

)} 

D. 

}} 

E. 

55 

F. 
G. 

5G  CANCER    OF   THE    STOMACH 

unconnected  with  the  stomach.      They  are   classified 
as  follows  : — 

Ascites  and  pleuritic  effusion     .      7  cases 
Matted  intestine      .  .  .      3    ^^ 

Intestinal  obstruction        .  .      2    ,, 

Abdominal  suppuration    .  .      2    ,, 

Profound  antemia    .  .  .      2     „ 

Iliac  tumour  .  .  .1    case 

Thrombosed  veins  .  .  .      ?     ,, 

In  all  the  gastric  symptoms  were  trivial^  and  in 
many  the  stomach  disease  was  only  discovered  at 
autopsy. 

In  the  ordinary  course  the  symptoms  commence 
with  loss  of  appetite  and  want  of  vigour^  often 
coming  on  in  an  individual  suddenly  and  without 
any  apparent  cause ;  loss  of  flesh  is  soon  noticed, 
with  pallor  and  shortness  of  breath,  discomfort  after 
food  is  usually  felt,  which  may  pass  on  to  pain  and 
a  feeling  of  sickness,  and  after  a  time  vomiting  of 
food,  little  or  much  altered.  At  first  the  vomit  is 
usually  free  from  blood,  but  in  the  later  stages, 
when  the  cancer  begins  to  ulcerate,  it  is  signalled  by 
coffee-ground  vomit.  Rarely  blood  is  vomited  in 
quantity,  and  only  very  rarely  does  ha3matemesis 
assume  a  serious  form  in  gastric  carcinoma,  though 
I  have  known  it  to  directly  cause  death  on  four  occa- 
sions. Pyrosis  is  frequently  complained  of  in  the  early 
stages  of  the  disease.  The  bowels  are  usually  con- 
stipated.     After  a  longer  or  shorter  interval,  weeks. 


PLATE   III. 


Cancer  of  cardiac  orifice  of  the  stomach. 
(No.  2422^  Royal  College  of  Surgeons'  Museum.) 


To  face  p.  bl 


Adlard  ^-  Son,  Impr, 


CANCER   OF   THE   STOMACH  57 

or  may  be  months^  a  tumour  may  develop  in  tlie 
epigastrium_,  and  then  the  symptoms  are  usually  so 
well  marked  that  no  doubt  can  be  entertained  as  to 
the  condition.  Enlargement  of  the  supra-clavicular 
glands  on  the  left  side  and  dulness  beneath  the  left 
clavicle  are  important  signs  indicating  advanced 
disease. 

On  quite  a  number  of  occasions  I  have  been  con- 
sulted for  abdominal  tumour  due  to  cancer  of  the 
stomach  without  any  of  the  characteristic  signs, 
except  general  failure  of  health  and  loss  of  flesh,  but 
in  such  cases  the  orifices  of  the  stomach  have  not 
been  involved  in  the  growth.  In  the  later  stages 
profound  ansemia,  oedema  of  the  limos,  ascites  and 
increasing  weakness  herald  the  approach  of  the 
end. 

If  the  disease  is  at  the  cardiac  end  of  the  stomach, 
involving  the  cardiac  orifice,  the  symptoms  may 
resemble  those  of  stricture  of  the  oesophagus  and  be 
associated  with  dysphagia  ending  in  an  inability  to 
swallow  at  first  solids  and  later  even  fluid  nourish- 
ment ;  in  such  cases  the  tumour,  being  well  under 
cover  of  the  ribs,  is  difficult  or  impossible  to  palpate, 
but  enlargement  of  the  supra-clavicular  glands  on 
the  left  side  is  usually  present. 

If  the  pylorus  be  the  part  involved  dilatation  of 
the  stomach  with  retention  and  decomposition  of 
food  and  vomiting  are  pronounced  symptoms,  the 
vomiting,   being    at  first     irregular,     perhaps  every 


58  CANCER   OF   THE    STOMACH 

second  or  third  day,  soon  becoming  daily,  and  later 
occurring  after  every  meal. 

Visible  peristalsis  is  not  usually  so  marked  as  wlien 
the  dihitation  is  due  to  simple  stenosis,  but  it  may 
be  a  prominent  sign,  and  is  then  usually  associated 
with  pain  that  is  relieved  by  vomiting. 

If  the  disease  attacks  the  centre  of  the  stomach 
it  may  lead  to  hour-glass  distortion  with  visible 
peristalsis  of  the  proximal  portion. 

In  some  cases  the  neoplasm  invades  adjoining- 
regions,  as  the  pancreas,  transverse  colon,  gall-bladder 
and  bile-ducts  and  liver,  producing  characteristic 
symptoms  such  as  jaundice  and  intestinal  obstruction. 

The  special  symptoms,  pain,  vomiting  and  tumour, 
may  be  considered  more  in  detail. 

Pa  1)1  is  very  variable  and  may  be  entirely  absent 
throughout  the  course  of  the  disease,  or  there  may  be 
discomfort  and  fulness  after  food  not  amounting  to 
actual  pain.  These  painless  cases  Brinton  gives  as 
8  per  cent.,  Lebert  25  per  cent.,  and  Osier  as  loo 
per  cent. 

In  the  majority  of  cases,  however,  estimated  at 
from  80  to  90  per  cent.,  pain  is  a  prominent  symptom. 
It  may  be  continuous,  with  exacerbations  after  food, 
or  may  only  be  felt  after  meals,  especially  after 
solids  have  been  taken. 

When  the  pylorus  is  involved,  leading  to  stenosis, 
peristalsis  is  usually  accompanied  by  severe  pain  of 
a  crampy  character  which  is  relieved  by  vomiting. 


CANCER   OF   THE    STOMACH  59 

The  pain  is  usually  referred  to  the  epigastrium, 
occasionally  passing  through  to  the  back,  especially 
in  the  left  subscapular  region,  or  even  being  only  felt 
there. 

As  a  rule  tenderness  is  absent,  the  disease  then 
presenting  a  great  contrast  to  gastric  ulceration. 

VumitiiKj  occurs  in  85  per  cent,  of  cases  of  cancer 
of  the  stomach  ;  it  is  usually  a  later  symptom  than 
pain.  If  the  stomach  is  dilated,  the  vomit  may  be 
large  in  quantity  every  second  or  third  day,  and  I 
have  seen  material  vomited  that  had  been  taken 
three  or  four  weeks  previously  ;  the  vomit  may  be 
offensive  and  fermenting,  more  so  than  is  generally 
seen  in  ordinary  cases  of  dilated  stomach.  If  the 
stomach  is  small,  vomiting  usually  occurs  oftener  and 
in  smaller  quantity  ;  but  when  the  disease  is 
involving  the  cardiac  orifice  there  is  regurgitation  of 
food,  but  no  actual  vomiting. 

Blood  is  vomited  in  about  half  the  cases  in  my 
experience,  though  Professor  Osier  only  gives  it  as 
a  percentage  of  28*1.  It  may  be  bright  in  colour 
and  very  profuse,  though  it  is  usually  dark,  like 
coffee-grounds.  In  four  cases  of  cancer  of  the 
stomach  I  have  known  htematemesis  to  cause  death. 

Fever  of  a  hectic  type  is  present  in  about  half  the 
cases  j  it  is,  however,  irregular,  and  may  be  absent  or 
the  temperature  may  even  be  subnormal  throughout. 

Tumour  is  discoverable  in  about  80  per  cent,  of 
all  cancers  of  the  stomach,  and  it  is  most  unfortunate 


60 


CANCER   OF   THE    STOMACH 


for  radical  treatment  tliat  in  such  a  large  proportion 
of  cases  this  sign  should  be  waited  for  before  the 
diagnosis  is  made  and  surgical  treatment  sought_,  for 
tumour  is^  as  a  rule^  a  late  manifestation^  and  usually 
affords  evidence  that  the  disease  is  no  longer  local. 


Fig.  4. — Various  positions  in  which  tumour  may  be  felt  in  cancer 
of  the  stomach. 

Though  the  presence  of  a  tumour  makes  it  pro- 
bable that  in  case  of  removal  of  the  growtli  there 
Avill  be  recurrence^  yet  the  rule  is  not  without  excep- 
tion, as  in  my  own  experience  I  have  a  patient 
living  and  well  over  six  years,  another  over  five 
years,  and  others  at  lesser  periods  after  gastrectomy 


CANCER   OF   THE    STOMACH 


Gl 


where  tumours  were  perceptible  before  operation. 
Koclier  and  other  surgeons  have  had  similar  expe- 
rience. 

We  should  be  able  to  make  our  diagnosis  (if  need- 
ful by  an  exploratory  operation)  before  a  tumour  can 


Fig.  5. — Various  positions  in  which  tumour  may  be  felt  in  cancer 
of  the  stomach. 

be  felt,  if  we  want   to   obtain  the  best  results  from 
the  surgical  treatment  of  gastric  carcinoma. 

Inspection  will  often  reveal  a  tumour  if  present, 
and  in  more  than  half  of  the  cases  I  have  observed, 
the  tumour  has  been  seen  visibly  moving  up  and  down 
during  respiration.       After  manipulation,  inspection 


62  CANCER   OF   THE   STOMACH 

will  frequently  reveal  visible  peristalsis  in  a  stomach 
dilated  from  obstruction  at  the  pylorus,  or  in  the 
proximal  portion  of  a  cancerous  hour-glass  stomach. 

Palpation  is  of  service,  not  only  in  discovering  a 
tumour,  but  in  estimating  its  mobility  in  a  vertical 
or  transverse  direction,  and  helping  to  form  some 
idea  as  to  the  possibility  of  removal ;  a  tumour  that 
is  freely  movable  during  respiration  or  under  mani- 
pulation may,  however,  be  too  fixed  for  successful 
removal. 

A  malignant  tumour  is,  as  a  rule,  nodular  and  irre- 
gular, but  it  may  be  smooth,  and  it  may  vary  in  size 
from  time  to  time  on  account  of  the  rigid  contraction 
of  the  gastric  muscular  coat  on  its  proximal  side ; 
it  is  usually  devoid  of  tenderness,  and  unlike  inflam- 
matory swelling  there  is  generally  an  absence  of 
rigidity  of  the  muscles  overlying  it. 

Much  information  as  to  the  position  and  size  of 
the  tumour  may  be  obtained  by  palpating  the  abdo- 
men with  the  stomach  artificially  inflated  by  carbonic 
acid  gas,  and  again  by  examining  it  when  it  has  been 
emptied. 

Although  tumours  of  the  stomach  usually  occupy 
the  epigastrium,  they  may  be  found  in  any  part  of 
the  abdomen,  even  in  the  pelvis.  I  have  removed  a 
pyloric  tumour  that  could  only  be  just  felt  beneath 
the  left  costal  margin,  and  have  also  removed  one 
that  I  could  easily  manipulate  into  every  region  of 
the  abdomen. 


PLATE    IV. 


Extremely  siiu\ll  stomaeli  dependent  on  neoplasm — 'leather-bottle 
stoniacli.' 

(No.  2408,  Eoyal  College  of  Surgeons'  Museum.) 


To  face  }\  G'ii 


Adlard  4-  .S'o?/,  Impr. 


CANCER   OF   THE    STOMACH  G3 

A  tumour  may  be  formed  by  an  atrophic  can- 
cerous stomach  (leather  bottle  stomach)^  in  which  the 
walls  are  thickened  by  cancerous  infiltration  and  the 
lumen  much  diminished.  A  photograph  of  such  a 
case  from  the  Royal  College  of  Surgeons  Museum  is 
shown . 

This  condition  may  be  simulated  by  cirrhosis  of 
the  stomach,  but  the  histor}^  is  much  longer  in  cir- 
rhosis, though  the  symptoms  may  be  almost  identical, 
so  similar  is  the  appearance  of  the  two  conditions 
that  a  naked-eye  inspection  cannot  always  differen- 
tiate them,  and,  in  fact,  an  examination  b}^  the 
microscope  of  several  museum  specimens  labelled 
cancer  has  shoAvn  them  to  be  simple  in  character. 

In  54  per  cent,  of  cases  the  tumour  is  at  the 
pylorus,  in  16  per  cent,  on  the  lesser  curvature,  in 
9  per  cent,  at  the  cardiac  end,  in  3  per  cent,  on  the 
anterior  wall,  in  4  per  cent,  on  the  posterior  wall,  in 
4  per  cent,  on  both  walls,  in  4  per  cent,  on  the 
greater  curvature,  and  in  6  per  cent,  it  is  diffuse 
(Lebert). 

Enlargement  of  the  supra-clavicular  glantls  on  the 
left  side  is  important  positive  evidence  of  cancer  of 
the  stomach,  and  the  sign  may  be  present  when  an 
abdominal  tumour  is  not  to  be  felt ;  but  the  absence 
of  this  sign,  as  pointed  out  by  Riegel,  has  no  value 
as  negative  evidence. 

The  supra-clavicular  glands  on  the  left  side  are 
more  frequently  involved  in  cancer    of   the   stomach 


64  CANCER   OF   THE    STOMACH 

than  is  generally  supposed,  and,  as  had  been  shown 
by  Dr.  Mitchell  Stevens  [British  Medical  Journal, 
February  9th,  1907),  in  many  cases  careful  percussion 
Avill  show  the  presence  of  glandular  enlargement  in 
the  clavicular  and  infra-cla>vicular  regions,  and  may 
thus  give  a  clue  to  the  nature  of  an  abdominal  disease. 
It  is  possible  that  these  glands  become  infected 
through  "  regurgitation  ^^  of  infected  lymph  conveyed 
by  the  thoracic  duct  from  the  site  of  disease,  but 
more  frequently  infection  occurs  by  direct  communi- 
cation of   the  disease  alono-  the  walls  of  the  thoracic 

o 

duct  extending  along  the  lymph-vessels  to  the  glands. 
The  right  clavicular  glands  are  seldom  afPected. 

Rarely  the  left  axillary  glands  are  enlarged,  and 
left  inguinal  glandular  enlargement  has  some  value 
as  a  positive  sign. 

Ascites  is  not  a  common  accompaniment  of  cancer  of 
the  stomach,  and  when  present  may  obscure  the  other 
signs  and  lead  to  difficulties  in  diagnosis  ;  it  usually 
occurs  when  the  growth  invades  the  serous  coat  and 
forms  secondary  deposits  in  the  peritoneum ;  it  is 
therefore  a  late  sign  and  contra-indicates  surgical 
treatment. 

Perforation  of  the  stomach  from  cancer  is  not  a 
very  rare  complication.  Brinton  gives  it  as  3^  per 
cent..  Osier  says  4  per  cent.  In  cancer,  the 
perforation  usually  occurs  slowly  and  leads  to  a  local 
abscess,  very  rarely  to  acute  perforative  peritonitis, 
though    I   have    seen    a    perforating     carcinoma    to 


PLA'i'E    V 


Perforation  of  the  stomacli  duo  to  sloughing-  cancer. 
(No.  2407,  Koyal  College  of  Surgeons'  Museum.) 


To  face  p.  65. 


Ad  lard  <)■  Son,  tmpi 


CANCER   OF   THE    STOMACH  65 

present   symptoms  as  acute  as  those    of  perforating 
peptic  ulcer. 

Metastases  occur  in  3  out  of  4  cases  according  to 
Ewaldj  or  according  to  Osier  in  39  out  of  45  cases. 
The  largest  number  occurred  in  the  lymph-glands — 
a  total  number  of  30  ;  and  of  these  the  gastro-hepatic 
were  affected  in  21,  the  peritoneal  in  9,  posterior 
mesenteric  in  Q,  supra-clavicular  and  posterior  medias- 
tinal in  2,  iliac,  bronchial,  pericardial,  anterior  medias- 
tinal and  axillary  in  1  each.  The  liver  was  the  seat 
of  metastases  in  23,  peritoneum  11,  pancreas  8,  bowels 
8  (small  bowel  3,  colon  2,  duodenum  1),  kidney  and 
lungs  each  4,  pleura  3,  spleen  and  diaphragm  each  2, 
ribs,  vertebrae,  skull,  ilium,  femur,  heart-muscle, 
pericardium,  abdominal  wall,  vesico-rectal  cul-de-sac, 
hydrocele  sac,  and  ureter  each  1. 

Metastasis  along  the  round  ligament  extending  to 
the  umbilicus  was  noted  by  Wickham  Legg,  and  has 
since  been  frequently  observed  ;  I  have  seen  it 
several  times  in  late  cases  and  have  found  it  at 
operation  undertaken  at  a  time  when  it  was  hoped 
the  disease  might  prove  to  be  removable.  It  shows 
itself  in  the  late  condition  as  a  hard  cord  extending 
to  and  involving  the  umbilicus,  and  this  sign  may  be 
present  when  no  tumour  can  be  felt. 

Ulceration. — If  the  subject  of  gastric  carcinoma 
survives  for  a  sufficient  length  of  time  the  disease 
will  break  down  leading  to  ulcer,  but  the  patient 
may  die  before  ulceration  occurs.     Osier  and  McRae 

5 


66  CANCER   OF   THE   STOMACH. 

found  ulceration  in  35  out  of  44  cases  that  came  to 
autopsy. 

Jaundice  may  be  due  to  direct  invasion  of  the 
bile-ducts  or  to  secondary  nodules  in  the  liver;  it  is 
usually  a  late  and  always  a  very  serious  sign. 

CEdema  of  the  feet  is  a  late  sign  often  dependent 
on  anaemia^  which  is  always  present  in  the  later  stages 
of  the  disease. 

Interstitial  pancreatitis,  as  shown  by  Cammidge^s 
reaction  in  the  urine  and  the  presence  of  fat  and 
muscle-fibres  in  the  f^ces,  may  occur  early  in  the 
disease  if  the  growth  becomes  adherent  to  the 
pancreas,  but  before  it  has  extended  into  the  organ ; 
but  when  the  pancreas  has  become  invaded  by  the 
growth  the  symptoms  become  exaggerated  and  the 
crystals  obtained  from  the  urine  by  Cammidge's 
reaction  take  two  to  three  minutes  to  dissolve  in 
dilute  sulphuric  acid,  instead  of  half  a  minute. 

If  the  pancreatic  duct  is  involved,  the  f^ces, 
normally  alkaline,  become  acid,  and  the  constipation 
usually  present  may  give  place  to  bulky  pale  motions 
with  a  tendency  to  diarrhoea. 

The  character  of  the  vomit  or  of  the  stomacJi  contents. 
— If  the  patient  is  sick,  the  vomited  matter  can  be 
examined,  but  in  the  absence  of  sickness,  lavage  of 
the  stomach  should  be  performed  an  hour  after  an 
Ewald's  test  meal.  Before  coming  to  a  definite 
decision  it  is  desirable  that  the  analysis  should  be 
repeated  several  times. 


CANCER   OF   THE    STOMACH  67 

The  absence  of  free  HCl  is  in  favour  of  cancer,  as 
is  the  presence  of  lactic  acid,  but  the  presence  of 
some  free  HCl  and  the  absence  of  lactic  acid  have 
no  negative  value. 

In  gastric  carcinoma  there  is  seldom  found  a 
normal  amount  of  free  HCl,  and  never  an  excess 
except  in  ulcus  carcinomatosum  ;  the  presence  of  an 
excess  of  free  HCl  is  therefore  decidedly  in  favour 
of  ulcer. 

In  ulcus  carcinomatosum,  hoAvever,  there  is  usually 
a  large  amount  of  free  HCl  in  the  stomach  contents 
after  a  test  meal. 

In  90  per  cent,  of  cases  of  cancer  collected  from 
various  sources  by  Professor  Osier  there  was  an 
absence  of  free  HCl  in  the  stomach  contents. 

Digestive  pi'operties  of  stomach  contents. — This  may 
be  proved  by  testing  the  digestive  power  on  albu- 
minous foods  of  the  fluid  removed  after  a  test  meal, 
or  by  Schwarz^s  method  of  examining  by  the  Rontgen 
rays  after  the  patient  has  swallowed  a  bolus  of  bis- 
muth wrapped  in  an  envelope  of  connective  tissue 
obtained  from  the  appendix  vermiformis  of  a  sheep. 

In  healthy  stomachs  six  to  seven  hours  after  the 
bolus  is  swallowed  the  connective  tissue  envelope 
should  have  dissolved,  and  the  bismuth  will  be  distri- 
buted, but  if  digestion  is  impaired  the  bolus  may 
remain  unbroken  for  from  ten  to  twenty  hours  later, 
and  will  be  seen  as  a  deep  black  spot  when  the  X 
rays  are  used. 


m  CANCER    OF   THE   STOMACH 

Microscopic  examination. — The  presence  of  new 
growth  in  the  vomit  or  in  the  fluid  removed  by 
lavage  is,  of  course,  of  prime  importance,  but  it  can 
only  rarely  be  found,  and  it  is  quite  unjustifiable  to 
attempt  to  obtain  it  b}^  mechanical  means,  such  as  scrap- 
ing or  brushing  away  portions  from  the  gastric  wall. 

The  discovery  of  the  Oppler-Boas  bacillus,  a  long, 
non-motile  bacillus  of  the  shape  of  a  base-ball  bat,  is 
said  by  various  authorities  to  be  an  indication  of 
carcinoma,  but  while  its  presence  is  presumptive 
evidence  in  favour  of  carcinoma  its  absence  has  no 
negative  value.  This  bacillus  is  usually  found  when 
lactic  acid  is  present  in  the  lavage. 

The  presence  of  yeast  cells  and  sarcin^  is  common 
to  dilatation  of  the  stomach  with  retention,  both  in 
simple  and  in  malignant  disease. 

The  discovery  of  blood  cells  may  be  due  to  ulcer 
or  cancer  ;  it  is  therefore  simply  a  sign  of  serious 
organic  disease. 

TJie  motor  functions  of  the  stomach  are  best  tested 
by  examination  of  the  stomach  after  a  test  meal  ; 
such  impairment  may  be  due  to  pyloric  stenosis  from 
any  cause,  or  due  to  cancer  of  the  body  of  the 
stomach,  or  even  to  chronic  gastritis,  but  in  neurosis 
the  motility  of  the  stomach  is  increased.  The  stomach 
ought  to  be  always  found  empty  the  first  thing  in 
the  morning  after  a  meal  taken  at  10  p.m.,  but  in 
health  there  should  be  no  food  present  in  the  stomach 
six  hours  after  the  last  meah 


CANCER   OF   THE    STOMACH  69 

Diagnosis. — In  advanced  carcinoma  there  is  usually 
little  difficulty  in  making  a  diagnosis,  the  only  mis- 
takes that  would  be  likely  to  occur  being  either  the 
mistaking  of  an  inflammatory  tumour  associated  with 
ulceration,  or  the  mistaking  of  a  syphilitic  tumour 
for  a  malignant  growth.  In  the  latter  case  the  his- 
tory and  the  result  of  specific  treatment  afford  clues 
to  the  diagnosis.  In  the  former,  induration  around 
an  ulcer,  the  long  history,  the  tenderness  on  manipu- 
lation, and  the  presence  of  free  HCl  in  the  vomit 
or  in  the  lavage  should  be  of  assistance ;  but  all 
surgeons  who  have  had  any  experience  must  have 
found  a  difficulty  at  times  in  deciding  on  a  diagnosis 
between  inflammatory  disease  and  growth,  even 
when  the  abdomen  is  opened. 

In  several  patients  of  this  kind  on  whom  I  have 
operated  for  large  growths  at  the  pylorus,  or  in  the 
body  of  the  stomach  with  extensive  adhesions  ren- 
dering removal  impossible,  and  with  enlargement  of 
the  glands  rendering  malignant  disease  extremely 
probable,  I  have  performed  gastro-enterostomy  with 
the  idea  of  giving  relief ;  yet  ultimately  complete  and 
perfect  recovery  has  occurred,  and  the  patients  are 
living  and  well  years  later,  showing  that  the  su^^- 
posed  cancer  was  evidently  only  inflammatory  thick- 
ening around  an  ulcer,  which  was  cured  by  setting 
the  parts  at  rest. 

The  presence  of  numerous  adhesions,  the  discrete 
character  of  the  enlarged  glands,  which  are   softer 


70  CANCER   OF   THE    STOMACH 

than  cancerous  ones^  the  absence  of  secondary 
deposits  in  the  viscera^  and  the  absence  of  funga- 
ting  growths  in  the  tumour  itself  are,  when  taken 
with  the  former-mentioned  points^  in  favour  of  simple 
tumour,  but  as  acknowledged  by  Osier,  Halsted, 
Finney,  and  many  other  workers,  it  is  impossible  in 
some  cases  without  a  microscopic  examination  to 
distinguish  between  simple  imflammatory  tumour 
and  cancer.  Fortunately  operation  is  of  service  in 
both  conditions,  therefore  no  harm,  but  only  good, 
should  result  from  the  performance  of  gastro-entero- 
stomy  in  either  disease  ;  and  even  if  the  pylorus  be 
removed  for  chronic  ulcer  thinking  it  to  be  cancer, 
and  a  new  healthy  passage  into  the  bowel  be  estab- 
lished, the  patient  should  be  the  gainer. 

Hypertrophic  stenosis  of  the  pylorus  is  compara- 
tively rare  at  the  age  in  which  cancer  is  usually 
found,  and  it  has  only  once  happened  to  me  to 
mistake  this  condition  for  a  neoplasm,  the  pylorus 
forming  a  perceptible  tumour.  On  opening  the 
abdomen  I  found  the  pyloric  tumour  smooth  and 
uniform,  and  on  exploring  the  stomach  I  found  a 
chronic  ulcer,  which,  by  keeping  up  a  state  of 
irritation  over  a  long  period,  had  led  to  spasm  and 
hypertrophy  of  the  pylorus  and  to  gastric  dilatation. 
The  excision  of  the  ulcer  and  the  performance  of 
gastro-enterostomy  cured  the  patient  and  led  to  the 
subsidence  of  the  hypertrophy  of  the  pylorus.  Boas 
(5)  has  called  attention  to  three  cases  of  this  kind  in 


CANCER   OF   THE   STOMACH  71 

which  the  irritation  gave  rise  to  a  mistaken  diagnosis. 
It  is^  however,  in  the  early  stages  that  errors  in 
diagnosis  are  most  likely  to  occur,  leading  to  a  fatal 
delay  in  cases  that,  if  diagnosed  early,  can  be  cured 
by  a  radical  operation ;  for  it  is  undoubtedly  proved 
that  at  first  the  disease  is  purely  local  and  that  its 
complete  removal  may  be  absolutely  curative. 

Treatment. — Medical  treatment  may  be  considered 
in  a  few  words  :  it  cannot  cure,  and  can  do  very  little 
even  to  prolong  life  ;  it  therefore  applies  only  to 
cases  too  advanced  for  surgical  treatment  or  where 
operation  is  declined.  It  aims  at  nourishing  the 
patient  as  much  as  possible,  and  at  relieving  pain  or 
other  symptoms  as  they  arise. 

Surgical  treatment  offers  the  only  chance  of  relief 
and  the  only  possible  chance  of  cure,  and  in  order 
that  the  best  results  may  be  obtained,  the  physician 
and  surgeon  must  act  in  concert,  so  that  by  a  timely 
diagnosis  an  operation  may  be  undertaken  at  the 
earliest  possible  date.  There  is  ample  evidence  to 
show  that  for  some  length  of  time  cancer  is  a  purely 
local  disease ;  and  just  as  in  the  breast,  the  tongue, 
and  the  uterus,  we  can  point  to  patients  living 
comfortable  and  happy  lives  years  after  the  removal 
of  the  disease,  so  in  gastric  cancer  it  is  reasonable  to 
assume  the  same  possibilities.  Here,  how^ever,  we 
are  faced  with  the  difficulty  of  a  sufficiently  early 
diagnosis  being  made,  and  it  is  not  only  necessary 
for  us   to    appeal    for   an     early,     exhaustive,     and 


72  CAKCEE   OF   THE   STOMACH 

persistent  investigation  into  suspicious  stomacli  cases, 
but  tliat  wlien  tlie  suspicions  are  becoming  confirmed 
an  early  surgical  consultation  may  be  lield,  and_,  if 
needful,  an  exploratory  oj^eration  carried  out  to 
complete  the  diagnosis.  Whenever  a  patient  at  or 
after  middle  age  complains  somewhat  suddenly  of 
indefinite  gastric  uneasiness,  pain  and  vomiting 
followed  by  progressive  loss  of  weight  and  energy, 
and  associated  with  anemia,  the  possibility  of  cancer 
of  the  stomach  should  be  recognised,  and  in  a 
suspected  case,  if  no  improvement  takes  place  in 
a  few  weeks  at  most,  and  if  repeated  examinations 
of  the  stomach  contents  after  test  meals  show 
diminished  digestive  power  with  a  diminution  or 
absence  of  free  HCl  and  the  presence  of  lactic  acid, 
an  exploratory  operation  is  more  than  justified.  As 
Professor  Osier  says,  the  important  aid  of  an  explora- 
tory operation  should  be  more  frequently  advised. 

Let  us  remember  also  that  to  prolong  the  in- 
vestigation uselessly  and  to  wait  until  a  tumour 
develops  is  to  lose  the  favourable  time  for  a  radical 
operation  ;  and  although  a  clinical  examination  of 
the  stomach  contents  and  a  general  examination  of 
the  patient  may  give  us  strong  grounds  for  suspicion, 
our  diagnosis  can  only  be  rendered  certain  by  a 
digital  examination,  which  may  be  effected  through 
a  small  incision  that  can,  if  needful,  be  made  under 
local  anaBsthesia,  though  better  under  general 
ansesthesia  with  little,  if  any,  risk. 


CANCER   OF   THE    STOMACH  73 

At  the  time  of  the  exploration  it  will  be  gene- 
rally advisable  to  have  everything  read}^  to  follow  up 
the  exploratory  procedure  by  whatever  further  opera- 
tion may  be  called  for.  It  may  be  discovered  that  the 
disease  is  manifestly  not  yet  malignant^  and  that 
some  curative  operation  is  necessary  to  bring  about 
relief. 

Or  it  may  be  found  that  the  disease  resembles 
malignancy  both  in  its  history  and  physical  signs, 
and  in  the  form  of  the  tumour,  which,  on  account  of 
extent  and  adhesions,  and  from  the  presence  of  en- 
larged glands,  it  seems  impracticable  to  remove  with 
any  hope  of  permanent  success,  but  in  which  a  gas- 
tro-enterostomy  or  some  allied  operation  may  be 
called  for  in  order  to  give  relief,  or  maybe  to  effect 
a  cure. 

The  following  examples  selected  out  of  many 
such  cases  on  which  I  have  operated,  and  which 
were  at  the  time  of  operation  extremely  ill,  and  sup- 
posed to  be  suffering  from  cancer  of  the  stomach,  are 
as  the  result  of  surgical  treatment  in  good  health 
years  later. 

(1)  A  medical  man,  aged  thirty-one  years,  who  was 
seen  with  Dr.  B —  and  Dr.  W — ,  had  had  dyspepsia 
for  seventeen  years;  this  had  been  more  severe  during 
the  preceding  twenty  months.  Sixteen  months  pre- 
viously vomiting  began,  and  from  the  outset  large 
quantities  were  ejected,  but  never  contained  blood. 
There  was  occasional   recurrence  of   similar  attacks. 


74  CANCER   OF   THE    STOMACH 

which  were  always  relieved  by  treatment.  In 
December^  1897,  the  stomach  reached  to  the  pubes, 
and  visible  peristalsis  was  present.  Eelief  followed 
dieting  and  lavage  nntil  March,  1898,  after  wliicli 
time  the  pain  w^as  almost  constant,  and  was  not  mate- 
rially worse  after  food  or  relieved  by  vomiting.  A  loss 
of  weight  had  occurred,  from  10  st.  to  8  st.  6h  lb. 
There  was  great  feebleness.  Gastro-enterostomy  was 
performed  on  May  6tli,  1898.  A  large  irregular 
tumour  was  found  at  the  pylorus  and  along  the  lesser 
curvature  with  extensive  adhesions,  but  the  glands, 
though  large,  were  discrete.  A  good  recovery  was 
made  and  was  followed  by  relief  of  all  symptoms. 
When  the  patient  left  the  home  on  June  7th  his  weight 
was  8  st.,  on  August  1 7th,  1898,  it  was  9  st.  3  lb.  The 
following  is  an  extract  from  a  letter  from  the  patient, 
dated  February  12th,  1900  :  "  My  health  continues 
perfect.  I  have  not  lost  a  day^s  work  through  illness 
since  I  recovered. ^^  He  is  in  good  health  in  1906, 
eight  years  after  operation. 

(2)  Mr.  B — ,  aged  thirty-nine  years,  seen  Decem- 
ber, 1901,  on  account  of  pain  about  two  hours  after 
food,  with  the  passage  of  mel^na  and  great  loss  of 
flesh.  An  indefinite  tumour  could  be  felt.  On  opening 
the  abdomen  on  December  19th,  1901,  a  tumour  was 
discovered  involving  the  pylorus  and  the  first  and 
second  part  of  the  duodenum,  which  were  thickened 
and  infiltrated,  forming  a  sausage-shaped  tumour, 
very  hard  and  nodular   and  adherent  to    the    neigh- 


CANCER   OF   THE    STOMACH  75 

boiiring  pai'ts,  so  that  it  was  impossible  to  remove  it. 
A  posterior  gastro-enterostomy  was  therefore  per- 
formed, the  operation  being  concluded  under  the 
idea  that  the  patient  was  suffering  from  cancer.  As 
events  proved  this  Avas  clearly  an  error,  for  in 
January,  1903,  he  wrote  to  say  that,  although  he  had 
had  two  attacks  of  pain  due  to  over-indulgence,  he 
was  very  well  and  able  to  do  his  work,  and  that  the 
stomach  swelling  had  entirely  disappeared. 

(3)  The  patient,  a  man,  aged  forty-five  years,  gave 
a  history  of  pain  for  two  years  about  an  hour  after  food, 
with  great  loss  of  flesh.  For  nine  months  he  had 
vomited  every  day  or  every  second  day  a  large  quan- 
tity of  yeasty  material,  but  no  blood,  though  he  was 
very  ana3mic.  There  were  well-marked  signs  of  dilata- 
tion of  the  stomach,  with  tenderness  over  the  pylorus, 
and  the  presence  of  a  tumour.  Posterior  gastro- 
enterostomy was  performed  on  June  12th,  1900.  On 
opening  the  abdomen  the  pylorus  was  found  to  be 
much  thickened  and  adherent,  forming  a  hard, 
nodular  tumour  having  the  appearance  and  feel  of 
cancer.  Through  the  centre  of  the  mass  a  No.  10 
catheter  only  could  be  passed  over  a  roughened,  ulcer- 
ated surface.  An  uninterrupted  recovery  followed  ; 
food  was  begun  on  the  second  day,  and  solids  could 
be  taken  in  the  second  week  without  pain.  He 
rapidly  gained  flesh  and  strength,  and  was  well  in 
1903.      Many  other  similar  cases  could  be  related. 

I  would    lay    particular    stress    on    this    class   of 


76  CANCER   OF   THE   STOMACH 

cases,  for  I  tliink  it  serves  to  explain  some  mis- 
conceptions about  cancer  generally.  It  would  be 
easy  for  one  to  raise  a  claim  to  having  cured  a 
number  of  cases  of  cancer  of  the  stomach  by  gastro- 
enterostomy ;  but  I  do  not  for  a  moment  believe 
that  any  of  these  cases  were  more  than  inflammatory 
tumours  formed  around  chronic  gastric  ulcers;  never- 
theless I  have  no  doubt  that  they  would  have  proved 
fatal  just  as  certainly  as  if  they  had  been  cancer  had 
no  operation  been  done.  This  raises  an  interesting 
point,  and  that  is  the  alleged  increase  of  cancer,  for 
I  feel  sure  that  many  cases  like  those  related  above 
would  have  been  certified  as  deaths  from  cancer  of 
the  stomach  had  no  operation  been  done,  or  no 
necropsy  and  microscopic  investigation  made,  and  I 
think  we  must  take  such  cases  into  account  before 
hastily  deciding  that  this  disease  is  on  the  increase, 
though  other  evidence  seems  to  prove  the  fact. 

The  cases  also  illustrate  another  point :  even 
though  a  tumour  be  present,  and  even  though  it  be 
probably  too  large  for  removal,  it  may  be  quite  worth 
while  advocating  an  exploration,  to  be  followed  up 
by  gastro-enterostomy  if  that  be  practicable,  in  the 
hope  that  the  disease  may  prove  to  be  wholly  or  partly 
inflammatory,  which  the  physiological  rest  secured  by 
gastro-enterostomy  will  either  cure  or  material  1}^ 
relieve. 

To  pass  to  the  genuine  cancer  cases,  Avhat  can  we 
do  for  them  when  diagnosed  at  an  early  stage  ?    This 


PLATE    VI. 


Cancer  of  cardiac  end  of 
stoiuacli  with  dilated  oeso- 
phagus. 

(No.  2-417,  Eoyal  College  of 
Surgeons'  Museum.) 


Cancer  of  cardiac  end  of  stomach, 
associated  with  cancer  of  the  lower 
end  of  the  oesophagus. 

(No.  2421,  Royal  College  of  Surgeons' 
Museum. ) 


To  face  p.  77. 


Adlard  ij-  Son,  Impr. 


CANCER   OF   THE   STOMACH  77 

will  depend  :  (1)  on  the  position  of  the  growth  ; 
(2)  on  its  extent ;  (3)  on  the  presence  of  adhesions ; 
and  (4)  on  glandular  invasion  or  secondary  growths. 

First  as  to  position.  In  irremovable  growth  at 
the  cardiac  end,  if  it  involve  the  cardiac  orifice  and 
adjacent  portion  of  the  stomach,  gastrostomy  or 
jejnnostomy  should  be  performed  in  order  that  star- 
vation may  be  staved  off.  The  view  that  gastro- 
stomy is  both  a  dangerous  and  useless  operation  is,  I 
know,  held  by  some,  but  I  feel  convinced  that  such 
views  are  mistaken  ones.  When  these  cases,  either 
of  cancer  of  the  cardiac  end  of  the  stomach  or  of 
the  oesophagus,  were  handed  over  to  the  surgeon  in 
a  moribund  condition,  the  mortality  of  gastrostomy 
was,  of  course,  terrible,  and  the  short  survival  of  the 
cases,  even  if  successful  from  an  operative  point  of 
view,  made  the  procedure  almost  useless,  but  when 
one  can  point  to  a  series  of  gastrostomies  performed 
since  1897,  with  only  a  5  per  cent,  mortality  and 
with  great  prolongation  of  life  to  many  and  alleviation 
of  suffering  to  all,  I  feel  that  there  are  grounds  for 
saying  that  the  operation  is  well  worth  doing.  The 
operation  is  quite  a  simple  one,  and  if  necessary  can 
be  performed  under  cocaine  anaesthesia  in  a  very 
short  time.  In  several  cases  the  patients  have  lived 
a  year  or  more,  and  have  gained  considerably  in 
weight,  even  up  to  1^  st.,  and  have  lost  their  pain 
and  the  distressing  sense  of  starvation. 

The  next   class    of    cases  is    that   in    which    the 


78  CANCER   OF   THE   STOMACH 

disease  is  even  more  extensive,  involving  a  great  part 
or  the  whole  of  the  stomach,  the  disease  being  irre- 
movable and  gastro-enterostomy  impracticable,  and  in 
which  any  attempt  at  taking  food  brings  on  pain  and 
vomiting,  so  that  the  patient,  unless  relieved,  must 
rapidly  die  in  great  distress ;  here  a  jejunostomy 
can  be  performed  by  a  very  simple  and  similar 
procedure  to  that  of  gastrostomy,  and  through  a 
Jacques  catheter  sufficient  food  can  be  given  to  ward 
off  starvation  and  relieve  the  pain  caused  by 
attempts  at  taking  food  by  the  mouth.  This  operation 
can  be  done  through  the  small  exploratory  incision, 
and  need  involve  very  little  longer  time.  It  may  pro- 
long life  for  months  or  even  for  a  year,  and  make  the 
end  much  easier,  and  certainly  less  painful.  I  reported 
a  case  of  jejunostomy  in  1891  in  which  the  patient 
lived  three  months,  and  in  1904  one  that  had  lived 
twelve  months  after  jejunostomy,  and  the  fact  of  my 
case  of  almost  complete  gastrectomy  being  well  over 
six  years  after  operation  and  of  the  well-being  of 
other  complete  gastrectomies  shows,  not  only  that  the 
passage  of  food  direct  into  the  small  intestine  may  be 
compatible  with  comfort,  but  that  the  digestive 
processes  may  be  carried  out  completely.  Although 
the  operation  of  jejunostomy  is  rarely  called  for, 
it  is  one  nevertheless  which  should  be  borne  in 
mind,  as  in  an  appropriate  case  it  may  confer  a  great 
boon,  and  render  tolerable  an  otherwise  comfortless 
existence.      The  following  is  an  example  : 


CANCER  OF   THE    STOMACH  79 

Mrs.  C — ,  aged  forty-six  years,  tlie  wife  of  a  sea 
captain,  was  sent  to  see  me  on  April  8tli,  1904,  wlien 
she  was  suffering  great  pain,wliicli  came  on  at  frequent 
intervals,  and  slie  was  vomiting  five  or  six  times  a 
day  ;  in  fact,  whenever  she  took  food  it  w^as  shortly 
vomited,  the  vomit  being  at  times  coffee-ground  in 
character.  A  tumour  in  the  epigastrium  about  the 
size  of  a  large  flat  orange  could  be  readily  felt,  and 
at  short  intervals  the  whole  stomach  became  hard 
and  rigid.  No  enlarged  glands  could  be  felt  in  the 
groin  or  above  the  clavicle.  There  was  no  tender- 
ness on  pressure,  and  the  hard,  nodular  tumour  was 
suggestive  of  cancer.  Though  she  gave  a  history  of 
indigestion  and  loss  of  health  for  eight  years  or 
even  longer,  the  acute  symptoms  had  only  existed 
for  six  months. 

On  April  13th  the  abdomen  was  opened  by  a 
vertical  incision  through  the  inner  margin  of  the 
right  rectus,  Avhen  the  stomach  was  found  to  be 
involved  in  cancer  from  end  to  end,  and  as  the  glands 
along  the  lesser  curvature  were  involved  and  others 
could  be  felt  passing  up  through  the  opening  in  the 
diaphragm,  and  a  number  also  in  the  great  omentum, 
it  was  clearly  impossible  to  perform  gastrectomy  and 
impracticable  to  do  a  gastro-enterostomy.  A  loop  of 
jejunum  was  therefore  brought  up  and  short-circuited 
by  suture  over  a  decalcified  bone  bobbin,  and  a 
No.  12  Jacques  catheter  w^as  inserted  as  described  on 
page  206.      The  wound  was  rapidly  closed  and  the 


80  CANCER   OF   THE    STOMACH 

patient  was  put  to  bed  in  good  condition,  the  whole 
operation  only  having  occupied  half  an  hour  or  less. 
A  meal  of  peptonised  milk  was  given  at  once  and 
repeated  every  two  hours.  From  the  time  of 
operation  the  vomiting  was  never  repeated,  and  she 
completely  lost  her  pain.  She  returned  home  on  the 
nineteenth  day,  having  gained  flesh  and  strength. 

After  the  patient's  return  home,  on  May  17th,  I 
received  a  letter  to  say  :  "  Mrs.  C —  is  doing  wonder- 
fully well.  No  pain  or  sickness,  and  taking  as  much 
food  as  she  requires.  She  is  very  content,  and  is,  I 
think,  gaining  flesh  and  strength,  so  that  the  result 
is  even  better  than  you  had  hoped  for  and  much 
better  than  I  ever  expected.  She  is  very  grateful." 
She  lived  for  a  year,  and  during  eleven  out  of  the 
twelve  months  in  comfort. 

The  third  class  of  cases  to  be  considered  is  where 
the  disease  involves  the  pylorus  and  is  producing 
obstruction  to  the  passage  onwards  of  the  gastric 
contents,  but  where,  on  account  of  the  extreme  feeble- 
ness of  the  patient  or  because  of  extensive  adhesions, 
secondary  growths,  or  involvement  of  glands,  it  is 
considered  unwise  to  attempt  pylorectomy  or  partial 
gastrectomy,  though  there  is  sufficient  free  stomach 
wall  left  to  enable  a  gastro-enterostomy  to  be 
performed.  In  such  cases  a  gastro-enterostomy,  if 
performed  with  proper  expedition  and  adequate 
precautions,  affords  the  greatest  relief  to  the  sufferer, 
who    not   only  loses    the     distress    due    to    paiuful 


PLATE    VII. 


Colloid  cancer  of  pylorus  prodncing-  stenosis. 
(No.  2420,  Royal  College  of  Surgeons'  Museum.) 


To  facp  p 


A(lhn-((  i  Son,  Tmpr. 


CANCER   OF   THE   STOMACH  81 

peristalsis  and  to  the  irritation  of  retained  secretion^ 
but  also  becomes  freed  from  the  toxsemia  due  to 
absorption  of  the  poisonous  fermenting  stomach 
contents^  which  are  drained  away  into  the  intestine 
and  there  disposed  of.  Thus  life  is  prolonged  and 
made  more  comfortable,  flesh  and  colour  are  regained, 
and  even  in  cases  of  cancer  the  patient  may  have 
a  new  lease  of  life ;  in  one  of  my  cases  the  patient 
lived  over  two  years.  Moreover,  in  some  cases  where 
the  condition  of  the  patient  and  not  simply  the  extent 
of  the  growth  has  prevented  a  radical  operation  the 
speedy  restoration  to  health  enables  a  radical  opera- 
tion to  be  subsequently  undertaken.  The  following 
cases  out  of  many  others  that  could  be  cited  serve 
to  illustrate  what  I  mean  : 

Case  I. — Mr.  B — ,  aged  sixty-two  years.  Symptoms 
for  a  year.  Epigastric  tumour  noticed  a  month.  No 
free  HCl  in  vomit.  Exploratory  operation  November 
15th,  1900.  Ring  of  cancer  found,  forming  hour- 
glass-shaped stomach.  Patient  too  ill  for  gastrectom}^ 
Posterior  gastro  -  enterostomy  performed.  Good 
recovery.  December  20th,  a  month  later,  partial 
gastrectomy  performed,  the  ring-  of  growth  being- 
removed  and  the  proximal  and  distal  ends  of  the 
stomach  being  fixed  together  over  a  large  bone 
bobbin.  Good  recovery;  returned  home  within  the 
month.  Quite  well  a  year  later.  Letter  from  Dr. 
G — ,  November,  1902,  to  say  that  Mr.  B —  had  put 
on  flesh,  gained  colour,  and  been  able  to  take  food 

6 


82  CANCER   OF   THE    STOMACH 

well  for  over  a  year^  but  liacl  succumbed  to  exliaustion 
from  secondary  growths  in  the  omentum  March  oOth^ 
1902^  about  eighteen  months  after  operation. 

Case  2. — Miss  B — ,  aged  twentj-four  years.  Five 
years^  history  of  stomach  symptoms  with  great  loss  of 
flesh  and  recently  coffee-ground  vomit  with  tumour  at 
epigastrium.  Exploratory  operation  April  17th^  1902. 
Large  tumour  found  involving  the  pylorus  and  ante- 
rior wall  of  the  stomach.  Enlarged  glands  rendered 
gastrectomy  inadvisable.  Posterior  gastro- entero- 
stomy performed.  Good  recovery  and  returned  home 
on  the  nineteenth  day.  Seven  months  later  Dr.  W — 
wrote  to  say  that  the  patient,  who  weighed  4  st.  5  lb. 
at  the  time  of  operation,  on  September  1st  weighed 
8  st.  \\  lb.,  thus  nearly  doubling  her  weight  in  five 
months,  but  that  she  had  recently  developed  jaundice, 
possibly  due  to  extension  of  the  growth  to  the 
common  bile-duct. 

Case  3. — Mr.  B — ,  aged  thirty-six  years,  seen  with 
a  manifest  tumour  of  the  stomach  October  26th,  1901, 
and  with  a  history  of  stomach  trouble  extending  over 
several  years,  with  vomiting  of  blood  and  passage 
of  mela^na  on  two  occasions  within  the  preceding  four 
months.  At  the  operation  a  large  tumour  involving 
the  duodenum  and  pyloric  end  of  the  stomach,  too 
adherent  for  removal,  was  found  and  gastro- 
enterostomy performed.  After  the  operation  he 
went  abroad  and  for  six  months  he  rapidly  gained 
weight  and  felt    very  well.      He   then  began  to  get 


CANCER   OF   THE  8T0MACH  83 

tliinner  and  lose  strength,  and  without  any  pain  he 
gradually  lost  strength  and  succumbed  in  September, 
1902,  eleven  months  after  operation. 

Case  4. — The  patient  was  a  married  woman,  aged 
thirty-seven  years,  who  was  seen  with  Dr.  D — . 
Cancer  of  the  body  of  the  stomach  and  pylorus  with 
dilatation  was  diagnosed.  Gastro-enterostomy  was 
performed  on  December  21st,  1899.  She  made  a 
good  recovery  and  was  so  well  that  gastrectomy  was 
advised,  but  cancer  of  the  uterus  supervened  and 
prevented  further  operation.  She  lived  for  nine 
months  and  was  able  to  take  ordinary  food. 

Case  5. — The  patient,  a  man, aged  sixty-three  years, 
had  had  symptoms  for  five  years,  at  first  those  of 
chronic  ulcer,  later  those  of  malignant  ulcer  with 
tumour  associated  with  ha3matemesis.  Gastro-en- 
terostomy was  performed  on  March  22nd,  1901. 
He  made  a  good  recovery.  He  returned  home  at 
the  end  of  the  month  and  o-ained  4  lb.  in  weio'lit 
during  the  fourth  week.  He  ultimately  gained 
about  2  st.  and  lived  for  a  time  in  great  comfort, 
but  the  growth  progressed  and  he  succumbed  to 
exhaustion  about  a  year  later,  having  been  able  to 
enjoy  life  for  some  mouths. 

Case  6. — Mr.  W — ,  aged  sixty-eight  years,  operated 
on  July  18th,  1902,  for  pyloric  tumour  with  dilatation 
of  the  stomach,  the  patient  being  extremely  feeble 
and  sufferiug  great  pain.  The  disease  appeared  to  be 
cancer,  and  the  glands  were  extensively  involved  so 


84  CAXCP]R   OF   THE    STOMACH 

that  gastro-enterostomy  only  could  be  performed. 
X  letter  from  Dr.  S —  says  :  "  Patient  gained  10  lb. 
up  to  November^  and  is  now  14  lb.  heavier  than 
before  he  fell  ill  last  June.  He  is  able  to  take 
regular  exercise,  and  had  never  felt  any  pain  after 
taking  any  meal  whatever  since  the  operation.^^  He 
was  well  over  three  years  later. 

Other  cases  could  be  given,  but  these  will  suffice 
to  show  the  beneficial  effects  of  gastro-enterostomy 
even  in  advanced  cases  of  cancer  of  the  stomach;  for, 
as  will  be  seen  immediately,  it  is  only  in  the  cases  too 
advanced  for  removal  that  the  short-circuiting  opera- 
tion should  be  performed. 

The  operation  can  be  done  with  little  risk,  as  in- 
cluding all  my  cases  of  posterior  gastro-enterostomy 
for  cancer  performed  during  the  past  ten  years  the 
mortality  is  only  3'4  per  cent. — a  great  contrast  to  the 
death  rate  of  these  cases  a  few  years  ago. 

The  remaining  class  of  cases  is  of  great  interest, 
and  includes  those  where  the  disease  is  limited  to  the 
stomach,  and  where  the  lymphatic  glands  and  ad- 
joining organs  have  not  been  seriously  invaded,  the 
patient  being  in  a  sufficiently  good  condition  to  per- 
mit of  the  radical  operation  of  gastrectomy  being- 
done.      The  following  are  examj^les  : 

Mrs.  J — ,  aged  fifty  years.  Symptoms  five  months : 
tumour  noticed  three  weeks.  Operation  January 
31st,  1901.  Tumour  found  involving  the  whole  cir- 
cumference of    the    pyloric    end    of    the   stomach    a 


CANCER   OF   THE    STOMACH  85 

sliort  distance  from  tlie  pylorus.  After  the  growth 
had  been  widely  excised  the  distal  and  proximal  ends 
of  the  stomach  were  brought  together  over  a  large 
bone  bobbin.  Glands  were  excised  from  the  lesser 
and  also  from  the  greater  omentum.  Smooth  re- 
covery. On  January  4thj  1903,  two  years  later, 
Dr.  F —  was  kind  enough  to  write  and  tell  me  that 
the  patient  was  remarkably  well.  She  remained  well 
until  1905,  when  there  were  signs  of  recurrence. 

Mrs.  S — ,  aged  fifty-four  years.  Loss  of  flesh  and 
pain  with  failing  health  for  eight  months;  slight  jaun- 
dice and  tumour  in  epigastrium,  also  right  hypochon- 
drium  for  a  shorter  period.  Operation  August  9th, 
1900.  The  gall-bladder,  containing  gall-stones,  and 
the  site  of  the  tumour  was  removed.  As  the  ad- 
joining portion  of  the  liver  was  involved,  a  wedge- 
shaped  partial  hepatectomy  was  performed,  and  as 
the  pylorus  was  also  the  site  of  growth  a  partial 
gastrectomy  including  the  pylorus  was  done,  the  cut 
section  of  stomach  being  united  to  the  duodenum  by 
two  continuous  sutures  over  a  bone  bobbin.  The 
removed  tumour  examined  microscopically  after 
operation  proved  to  be  cancer.  That  part  of  the 
abdominal  wall  to  which  the  tumour  had  been 
adherent  was  also  excised.  She  was  reported  well 
in  1906. 

Mr.  A — ,  middle-aged,  who  had  been  ailing  for 
a  year,  and  had  had  stomach  symptoms  for  three 
months  and  a  noticeable  tumour  for  six  weeks,  was 


86  CAXCER   OF   THE   STOMACH 

supposed  to  be  too  ill  and  anaemic  for  operation,  but 
as  tlie  tumour  wliicli  was  situated  in  tlie  left 
hypocliondrium  and  epigastrium  was  freely  movable 
I  decided  to  operate.  On  May  23rd,  1902,  I  found 
a  mass  of  cancer  involving  the  centre  of  tlie  stomach, 
which  I  removed  along  with  some  glands  adjoining 
it.  Recovery  was  uninterrupted.  A  letter  dated 
January  22nd,  1903,  from  Dr.  M — ,  states:  "Patient 
very  well,  has  gained  14  lb.  in  weight.  No  evidence 
of  return  of  growth.  Able  to  transact  his  business." 
The  patient  lived  until  1905,  when  he  had  recurrence 
of  the  disease  and  died  some  months  later. 

In  1902  I  reported  a  case  in  extenso  where  I  had 
removed  the  whole  of  the  stomach,  except  a  small 
portion  of  the  dome  adjoining  the  oesophagus,  for 
malignant  disease  on  March  18th,  1901.  I  am  glad 
to  sa}^  that  this  patient,  over  six  years  later,  remains 
in  absolutely  good  health ;  he  has  a  good  appetite, 
enjoys  his  food,  and  is  able  to  attend  to  his  business 
as  usual.      The  following  are  notes  of  the  case  : 

^Ir.  — ,  aged  thirty-eight  years,  was  sent  to  me  on 
March  18th,  1901,  by  Dr.  11.  O.  Petrie,  Avith  the 
following  history  : 

He  had  since  childhood  always  complained  of 
flatulence  and  had  suffered  from  indigestion,  though 
he  had  only  been  ill  for  two  j^ears,  during  which 
time  he  had  suffered  from  fatigue,  with  some  loss  of 
strength  but  no  pain.  Six  months  ago  he  began  to 
have  pain  every  morning,  which   started   in   the  epi- 


CANCER   OF   THE    STOMACH  87 

gastriuin  and  passed  over  to  the  right  side  of  the 
abdomen.  There  was  no  pain  immediately  after 
food,  but  it  always  came  on  before  the  next  meal, 
when  food  gave  relief.  He  vomited  for  the  first 
time  the  week  before  seeing  me.  At  that  time  he 
had  an  attack  of  diarrhoea  which  was  thought  to  be 
due  to  a  chill.  He  had  never  been  constipated. 
There  had  been  great  loss  of  flesh  during  the  past 
twelve  months,  amounting  to  2  st.,  his  weight  when 
seeing  me  being  9  st.  1  lb.  He  looked  ill  and 
cachectic.  He  was  quite  sure  that  he  had  never 
vomited  blood  and  that  he  had  never  seen  blood  on 
the  motions. 

On  examining  the  abdomen  a  tumour  could  be  easilj^ 
seen  and  felt,  occupyiug  the  epigastric  region,  and 
extending  from  the  left  costal  margin  nearly  as  far 
as  the  right.  On  distending  the  stomach  with  air 
the  tumour  was  pushed  downwards,  but  there  did 
not  seem  to  be  much  dilatation.  The  tumour  had  a 
wide  range  of  mobility,  could  be  made  to  pass  to  the 
right  and  left  side  of  the  abdomen,  and  could  be 
pushed  up  under  cover  of  the  liver  and  down  below 
the  margin  of  the  ribs.  During  manipulation  the 
tumour  hardened  under  the  hand,  when  it  was  very 
distinct,  but  when  the  stomach  nmscle  was  relaxed 
the  growth  was  less  prominent.  There  was  no  free 
HCl  in  the  stomach  contents.  An  operation  was 
proposed  and  consented  to,  and  in  the  iDresence  of 
Dr.    Petrie    I   opened   the   abdomen    by    an    incision 


88  CANCER,   OF   THE    STOMACH 

tlirongli  the  right  rectus.  The  tumour  at  once  came 
into  view^  and  proved  to  be  a  firm^  nodular^  malig- 
nant growth  involving  nearly  the  whole  of  the  stomach 
from  the  pylorus  to  the  oesophagus,  the  only  portion 
of  the  organ  apparently  free  being  a  little  of  the 
dome  near  the  left  of  the  oesophageal  opening. 
There  was  no  ascites,  and  no  enlarged  glands  could 
be  felt,  nor  could  any  secondary  growths  be  seen. 

As  it  was  clearly  useless  to  perform  any  lesser 
operation,  and  as  the  tumour  was  so  mobile,  gas- 
trectomy was  decided  on. 

The  duodenum  an  inch  beyond  the  pylorus  was 
clamped  by  long  forceps  covered  with  rubber  tubing, 
the  lesser  and  then  the  greater  omenta  were  divided 
between  ligatures,  and  as  there  were  no  adhesions 
the  large  tumour  was  then  drawn  down,  and  the 
oesophagus  and  dome  of  the  stomach  were  clamped 
by  two  forceps  applied  from  the  left  and  right  side 
respectively.  The  stomach  was  then  cut  away  by 
scissors,  and  after  all  visible  vessels  had  been  liga- 
tured the  clamps  were  released  and  a  few  other 
bleeding  points  taken  up ;  but  throughout  ver}' 
little  blood  was  lost.  The  duodenum  was  brought 
across  the  spine  and  fixed  by  an  external  celluloid 
thread  and  an  internal  catgut  suture  around  a  de- 
calcified bone  bobbin  to  the  margin  of  the  stomach 
remaining  around  the  oesophageal  opening.  The 
duodenum  and  cardiac  end  of  the  stomach  seemed  to 
hold   together  with  very  little  tension.      The   opera- 


CANCER   OF   THE   STOMACH  89 

tion  had  been  effected  without  soiling  the  peritoneal 
cavity,  as  the  parts  had  been  isolated  throughout  by 
sterilised  gauze.  The  abdomen  was  closed  in  layers 
by  means  of  continuous  catgut  sutures_,  and  the 
patient  was  returned  to  bed  in  very  good  condition. 

He  was  allowed  to  take  a  little  liquid  nourish- 
ment with  plasmon  after  twenty-four  hours,  and, 
after  a  week,  light  custard  pudding.  Nourishment 
of  more  consistency  was  then  given,  and  within  the 
month  he  was  taking  minced  meat  and  other  ordinary 
foods.  A  breaking-down  haematoma  at  the  week  end 
delayed  healing  for  a  fortnight,  but  otherwise  re- 
covery was  uninterrupted,  and  he  was  able  to  return 
home  before  the  end  of  April. 

On  August  27th  I  received  a  letter  from  Dr. 
Petrie  to  say  :  "  Mr.  —  continues  well ;  I  saw  him 
to-day  and  he  has  become  considerably  stouter.^^ 

In  November,  1901,  he  called  to  see  me,  and  I 
failed  to  recognise  him  :  he  looked  healthy  and  fat, 
and  seemed  to  be  vigorous  and  well.  He  had  gained 
2  st.  in  weight.  He  said  that  his  digestion  was 
very  good  if  he  did  not  attempt  too  large  a  meal. 
He  gave  the  following  as  his  ordinary  diet  chart. 

7  a.m. — Breakfast  cup  of  boiled  milk  and  one 
table-spoonful  of  brandy. 

Breakfast. — One  e^g  boiled,  or  a  little  bacon, 
bread  and  butter,  one  cup  of  tea. 

11  a.m. — Breakfast  cup  of  boiled  milk  with  one 
table-spoonful  of  plasmon. 


90  CANCER   OF   THE    STOMACH 

Dinner. — Varying  as  follows  :  Lean  of  a  mutton 
cliop^  little  fisli,  chicken,  or  pigeon,  with  a  little 
cauliflower  and  bread,  always  milk  pudding,  chiefly 
rice. 

3  p.m. — Breakfast  cup  of  boiled  milk  and  one 
tea-spoonful   of  plasmon. 

Tea. — Bread  and  butter  or  a  little  toast,  one  cup 
of  tea. 

8  p.m. — Cup  of  milk  and  one  tea-spoonful  of 
plasmon. 

Supper. — Nearly  one  pint  of  boiled  milk  and  bread. 

In  1906,  over  five  years  after  operation,  he  was 
seen  by  the  matron  of  the  surgical  home  where  he 
staj^ed,  and  she  reported  him  as  looking  in  robust 
health  and  of  normal  Aveight.  He  Avas  again  reported 
well  in  1907. 

The  tumour  removed  Avas  a  nodular,  softish 
groAvth,  iuA^ohang  almost  the  Avhole  of  the  stomach, 
including  the  pylorus  and  extending  from  it  to  the 
cardiac  end,  AAdiere  a  small  margin  of  liealthy 
stomach  wall  remained.  It  Aveighed  1  lb.  immediately 
after  operation.  Unfortunately  the  specimen, 
Avhicli  Avas  sent  to  a  pathological  laboratory  to  be 
mounted  and  reported  on,  Avas  mislaid  and  cannot  be 
found.  It  is  impossible,  therefore,  for  me  to  say 
Avhether  it  Avas  sarcoma  or  cancer,  but  from  the 
absence  of  enlarged  glands,  from  the  rapidity  of 
growth  and  from  its  freedom  from  ndliesious  I  sus- 
pect that  the  growth  Avas  a  sarcoma. 


CANCER   OF   THE   STOMACH  91 

It  was  undoubtedly  malignant  and  was  invading 
tlie  stomacli  walls  generally ;  tlie  growth  was 
breaking  down  on  its  visceral  aspect,  and  tlie 
stomacli  cavity  contained  some  grumous  material 
thrown  off  from  the  growth.  The  pylorus  was 
invaded,  but  the  line  of  section  in  the  duodenum 
and  at  the  cardiac  end  of  the  stomach  showed  a 
healthy  appearance,  and  a  free  portion  existed 
between  the   growth  and  the   cut  margin. 

These  cases  out  of  others  that  I  could  relate  will 
be  sufficient  to  show  that  removal  of  even  a  con- 
siderable portion  of  the  stomach  may  be  something 
more  than  a  palliative  operation,  and  I  think  it 
justifies  me  in  saying  that  although  it  is  better  to 
have  cases  of  cancer  diagnosed  and  operated  on 
early,  yet  we  need  not  take  the  pessimistic  view 
which  has  been  given  by  some  surgeons  that  if  a 
tumour  be  manifest  it  is  too  late  to  perform  a 
radical  operation. 

I  hope  I  have  advanced  sufficient  evidence  to  prove  : 

(1)  How  desirable  it  is  to  make  an  earl 3^ 
diagnosis  of  cancer  of  the  stomach  in  order  that  a 
radical  operation  may  be  performed  at  the  earliest 
possible  moment. 

(2)  That  it  may  be  needful  to  perform  an 
exploratory  operation  in  order  to  complete  or 
confirm  the  diagnosis. 

(3)  That  such  an  exploration  may  be  clone  with 
little  or  no  risk  in  the  early  stages  of  the  disease. 


92  CANCEE    OF   THE   STOMACH 

(4)  That  even  where  the  disease  is  more  advanced 
and  a  tumonr  perceptible,  an  exploratory  operation 
is,  as  a  rule,  still  advisable  in  order  to  carry  out 
radical  or  palliative  treatment. 

(5)  That  where  the  disease  is  too  extensive  for  any 
radical  operation  to  be  done  the  palliative  operation 
of  gastro-enterostomy,  which  can  be  done  Avith  very 
small  risk,  may  considerably  prolong  life  and  make 
the  remainder  of  it  much  more  comfortable  and 
happy. 

(6)  That  some  cases,  thought  at  the  time  to  be 
cancer  too  extensive  for  removal,  may  after  gastro- 
enterostomy clear  up    completely  and  get  quite  well. 

(7)  That  in  cases  of  disease  of  the  cardiac  end 
of  the  stomach  too  extensive  for  removal  the 
operation  of  gastrostomy  may  considerabl}^  2^^'olong 
life  and  prove  of  great  comfort  to  the  patient  b}' 
preventing  death  from  starvation. 

(8)  That  even  where  the  disease  is  too  extensive 
either  for  removal,  or  for  a  gastro-enterostomy  or 
even  a  gastrostomy  being  performed  with  a  fair 
chance  of  success,  the  operation  of  jejunostomy  may 
prove  of  service  to  the  patient. 

(9)  That  where  a  radical  operation  can  be  per- 
formed, the  thorough  removal  of  the  disease  may 
bring  about  as  much  relief  to  the  patient  as  does  the 
operation  for  removal  of  cancer  of  the  breast,  uterus, 
and  other  organs  of  the  body,  and  that  in  some  cases 
a  complete  cure  may  follow. 


PLATE    VIII, 


Cancer  of  pylorus,  producing-  stenosis,  in  a  woman  ayed  thirty-six. 
(No.  2411a,  Koval  College  of  Suro-eons'  Museum.) 


Hour-o-lass  stomach,  possibly  congenital,  Avith  growth  round  cardiac  orifice. 
(No.  2416,  Eoyal  College  of  Surgeons'  Museum.) 


To  face  p.  92. 


AfUard  4"  Son,  Impr. 


CHAPTER    V 

SIMPLE  TUMOURS  OF  THE  STOMACH  THAT 
MAY  BE  MISTAKL]N  FOR  CANCER 

Benign  tumours  of  the  stoiiiacli  are  rare^  and 
unless  they  invade  the  orifices  may  produce  no 
symptoms^  though  when  ulcerating  they  may  simulate 
malignant  disease. 

Tumours  of  the  stomach  caused  by  chronic  ulceration. 
— It  may  be  possible  for  a  considerable  tumour  to 
develop  around  a  chronic  gastric  ulcer  and  to  simulate 
cancer,  both  in  its  physical  signs  and  symptoms. 
As  a  rule  the  length  of  time  during  which  the 
symptoms  have  continued  will  give  rise  to  a  suspicion 
of  ulcer,  but  on  the  other  hand  cancer  is  well  known 
to  be  predisposed  to  by  ulcer,  and  in  such  cases  the 
presence  of  a  well-marked  tumour  cannot  but  fail  to 
give  rise  to  a  suspicion  of  cancer. 

The  presence  of  free  hydrochloric  acid  in  the 
vomit  or  in  the  lavage  after  a  test  meal,  though  in 
favour  of  ulcer,  is  no  certain  guide,  for  it  is  well 
known  that  in  ulcus  carcinomatosum  the  vomit  con- 
tains an  excess  of  free  HCl. 


94  CANCER   OF   THE   STOMACH 

On  several  such  cases  I  have  operated  and  per- 
formed a  gastro-enterostomy  on  finding  the  disease 
too  extensive  for  removal ;  but  the  complete  recovery 
of  the  patients  and  a  return  to  perfect  health  have 
shown  that  the  disease  must  have  been  simple. 

On  two  occasions  I  have  performed  partial 
gastrectomy  for  what  appeared  to  be  cancer^  and  only 
on  microscopic  investigation  has  the  disease  been 
found  to  be  simple.  On  one  occasion  I  found  a  large 
tumour  of  the  cardiac  end  of  the  stomach  which  I 
could  not  remove.  The  abdomen  was  closed  and  a 
bad  prognosis  given^  but  the  patient  recovered  and 
is  well  some  years  later. 

The  points  that  may  help  in  the  diagnosis  are 
the  duration  of  the  disease  and  the  great  pain  and 
tenderness  in  ulcer.  Even  wdien  the  abdomen  is 
opened  it  is  not  always  easy  to  differentiate  the  two 
diseases^  but  the  absence  of  nodules  on  the  growth 
and  of  secondary  nodules  in  the  omentum  together 
with  the  presence  of  discrete,  though  enlarged, 
lymph-glands,  may  be  of  some  help,  though  in  certain 
cases  the  only  way  to  decide  is  by  the  microscope. 

Plastic  linitis. — The  term  'Aplastic  linitis"  has  been 
used  somewhat  indefinitely  to  indicate  a  chronic 
induration  and  thickenino-  of  the  walls  of  the  stomach 

o 

w4th  a  marked  diminution  of  the  gastric  cavity. 

It  is  an  extremely  rare  condition  that  would  be 
seldom  described  if  all  cases  of  diffuse  sarcoma  or 
carcinoma  of  the  stomach  walls  could  be  excluded. 


SIMPLE   TUMOURS   OF   THE   STOMACH     95 

The  following  example,  in  wliicli  a  very  atypical 
epitlielioma  is  said  to  have  been  found,  but  which 
otherwise  corresponds  to  the  condition  under  con- 
sideration, serves  to  illustrate  the  indefinite  character 
of  the  affection  : 

Gayet  and  Patel  :  Total  gastrectomy  for  plastic 
linitis  {Arcli.  Gener.  de  Med.,  81st  year,  vol.  i, 
p.  770). — In  this  case  the  patient,  a  woman,  aged 
forty-four  years,  was  operated  on  for  gastric  cancer 
infiltrating  the  entire  walls  of  the  stomach.  Pro- 
fessor Jaboulay  performed  gastrectomy.  An  analysis 
of  the  gastric  contents  previous  to  operation  had 
given  total  acidity  I'OS,  HCl  1*13;  no  free  HCl  ; 
no  lactic  acid.  At  the  operation  no  enlarged 
lymphatic  glands  were  found  after  gastrectomy  ; 
the  duodenum  was  closed  and  a  loop  of  the  jejunum 
was  brought  up  to  a  small  piece  of  the  cardiac  end 
of  the  stomach  which  had  been  left.  On  micro- 
scopical examination,  after  many  sections  had  been 
made  it  was  found  that  the  lesion  was  a  very 
atypical  epithelioma  originating  in  a  chronic  in- 
flammation. The  inflammation  showed  nothing- 
specific  and  there  was  nothing  to  suggest  tuber- 
culosis, no  giant  cells,  no  disintegration,  no  glands. 

Roux  [Rev.  Med.  de  la  Suisse  Romande,  January 
20th,  1905)  reports  the  following  case:  A  coachman, 
aged  thirty-three  years,  was  admitted  to  hospital  on 
June  24th,  1901.  He  had  been  in  good  health  until 
September,    1900,  when    he    began    to    suffer    from 


96  CANCER   OF   THE    STOMACH 

gastric  distension  immediately  after  food,  acid 
eructations^  and  a  sensation  as  though  the  passage  of 
food  were  obstructed.  Appetite  was  good.  A  stay 
in  his  native  country  produced  great^  though 
temporary,  improvement_,  but  on  January  loth,  1901, 
he  began  to  vomit  after  each  meal.  If  food  were 
retained  for  any  time  it  produced  a  sensation  of 
gastric  oppression,  which  was  relieved  when  vomiting 
occurred.  The  returned  food  was  undigested.  He 
became  greatly  emaciated,  though  his  appetite 
remained  excellent.  There  was  no  mel^na,  and 
neither  hasmatemesis  nor  pyrosis.  The  haemoglobin 
was  75  per  cent.,  and  the  red  lips  contrasted  Avitli 
the  pallor  of  the  skin.  The  abdomen  was  retracted. 
It  was  difficult  to  palpate  the  epigastrium  on  account 
of  rigidity  of  the  recti  muscles,  especially  on  the 
right  side.  Traube^s  semilunar  space  was  extremely 
tympanitic.  After  a  test  meal  the  total  acidity  of 
the  gastric  juice  was  4*6  per  mille.  Free  HCl  was 
absent,  and  there  was  much  lactic  acid.  On  in- 
flation the  outlines  of  the  stomach  were  not  visible. 
A  diffuse,  inoperable  tumour  was  suspected. 
Laparotomy  was  performed  on  June  26th,  1901. 
The  stomach  was  small  and  rigid,  and  the  pyloric 
portion  was  grooved  by  a  number  of  irregularly- 
placed  circular  indentations,  which  resembled  those 
on  certain  Bologna  sausages.  It  was  hard,  and 
appeared  to  be  solid,  though  a  stomach-tube  could  be 
felt  indistinctly  to  be    arrested  at   about   the  middle 


SIMPLE   TUMOURS   OF   THE   STOMACH     97 

indentation.  The  superior  (cardiac)  half  of  the 
stomach,  though  less  indurated,  was  extremely 
thickened.  Total  gastrectomy  was  precluded  by  the 
condition  of  the  walls  and  the  numerous  adhesions 
about  the  cardiac  end.  Anterior  gastro-enterostomy 
appeared  to  oifer  the  best  chances,  and  to  be  the  only 
possible  procedure.  The  peritoneal  coat  was  thin. 
The  muscular  coat,  however,  was  more  than  1  cm. 
in  thickness  at  its  thinnest  part.  It  was  friable,  of 
a  colour  resembling  chamois  leather,  and  traversed 
by  dense  whitish  strands  of  connective  tissue.  In 
places  there  were  yellow,  fatty  patches.  On  opening 
the  mucosa  a  greenish,  bilious  fluid,  which  contained 
remnants  of  food  and  a  cherry-stone  swallowed 
three  or  four  days  previously,  escaped.  The  mucosa 
was  blackish,  h{\3morrhagic,  smooth  and  friable,  and 
appeared  to  be  superficially  ulcerated.  The  intro- 
duction of  a  finger  revealed  that  the  interior  of  the 
stomach  presented  no  trace  of  the  circular  folds 
present  on  the  surface.  Towards  the  pylorus  the 
finger  completely  filled  the  lumen.  Owing  to  the 
mobility  and  looseness  of  the  mucous  membrane  of 
the  coil  of  jejunum  selected,  there  Avas  no  difficulty 
in  approximating  the  mucous  membranes.  The 
opening  after  completion  of  the  sutures  easily 
admitted  two  fingers.  After  the  operation  there 
was  great  collapse,  but  with  the  constant  hypodermic 
adminstration  of  stimulants,  etc.,  the  man  rallied. 
On  July  11th  the  wound  had  healed  and  on   August 

7 


98  CANCER   OF   THE   STOMACH 

2nd  lie  was  discliarged_,  liaving  gained  more  than 
11  lb.     He  was  in  good  liealtli  in  tlie  spring  of  1904. 

In  true  plastic  linitis  there  is  no  evidence  of  new 
growth^  the  thickening  being  due  to  hypertrophy  of 
the  muscular  coat  and  infiltration  of  the  wall  of  the 
stomach  with  inflammatory  exudation,  Avhicli  in  places 
has  been  converted  into  fibrous  tissue.  An  almost 
similar  appearance  may  be  produced  by  cancer  as  in 
the  so-called  "  leather-bottle  stomach/^  of  which  a 
photograph  from  the  Royal  College  of  Surgeons 
Musenm  furnishes  a  good  example  (Plate  IV,  p.  63) . 

The  symptoms  are  those  of  chronic  gastric  irritation 
associated  with  epigastric  pain,  tenderness  and 
vomiting.  Emaciation  occurs  as  the  result  of 
inability  to  take  or  retain  food.  A  hard  tumour  in 
the  epigastrium  extending  nnder  the  left  costal 
margin  is  suggestive  of  carcinoma,  though  the  tender- 
ness of  the  epigastrium  and  the  rigidity  of  the  recti 
point  to  inflammation  rather  than  growth. 

Even  in  the  absence  of  new  growth,  free  HCl 
may  not  be  found,  as  in  Roux^s  case.  Owing  to 
the  presence  of  perigastritis  numerous  adhesions 
may  be  found. 

Treatment. — Medical  treatment  in  the  shape  of 
careful  dieting,  rest,  and  sedatives  will  have  usually 
been  tried  before  the  surgeon  sees  the  case.  In 
plastic  linitis   surgical  treatment  is  called  for. 

If  there  is  reason  to  believe  that  cancer  or 
sarcoma  are  not  causing  the  trouble,  a  well-planned 


PLATE    IX. 


Villous  g•l•o^vtll  near  lesser  curvature,  fuund  po.st  mortein  in  an  aged 

woman . 

(No.  2-iU7a,  Royal  College  of  Surgeons'  Museum.) 


Polyj)us  near  pylorus,  Avhicli  caused  death  by  vomiting. 

The  patient  was  a  woman  aged  ninety-two.     (No.  2405(?,  Eoyal  College 
of  Surgeons'  Museum.) 


To  face  p.  90. 


Adhird  cf-  Son,  Impr 


SIMPLE   TUMOURS   OF   THE    STOMACH     99 

gastro-enterostomy_,  as  in  Roux^s  case_,  offers  a  good 
chanco  of  relief    or    cure. 

If^  however^  tliere  is  a  suspicion  of  the  disease 
being-  malignant^  complete  gastrectomy  is  advisable, 
especially  if  the  organ  is  found  to  be  free  from 
complex  adhesions  and  the  lower  end  of  the 
oesophagus  can  be  dragged  down  sufficiently  to 
render  approximation  of  the  duodenum  or  jejunum 
possible. 

An  oesophageal  bougie  introduced  into  the  stomach 
through  the  oesophagus  renders  dissection  of  the 
cardiac  end  of  the  stomach  from  the  o'ullet  easier,  and 
it  also  facilitates  the  process  of  suturing  the  opening 
in  the  oesophagus  to  the  opening  in  the  bowel. 

If  the  patient^s  condition  or  the  anatomical 
arrangements  of  the  parts  renders  either  gastro- 
enterostomy or  gastrectomy  impracticable,  the 
operation  oE  jejunostomy  will  enable  the  patient  to 
be  fed  artificially,  and  by  giving  rest  to  the  stomach 
may  so  far  alleviate  the  symptoms  of  irritation  as 
to  enable  food  to  be  again  taken  by  the  mouth  after 
a  little  time. 

Adenoma. — Simple  glandular  tumours  of  the 
stomach  may  be  single  ur  multiple,  and  they  arc 
specially  liable  to  form  polypk  They  maybe  found 
in  any  part  of  the  stomach,  but  are  not  infrequently 
found  to  occur  at  the  pyloric  end,  where  they  may 
give  rise  to  pyloric  obstruction  and  dilatation  of 
the   stomach. 


100  CANCEE   OF   THE   STOMACH 

111  a  case  of  my  owii^  a  sessile  adenoma  gave  rise 
to  pyloric  obstruction  with  gastric  dilatation^  wliicli 
was  cured  l)y  removal  of  the  growth^  the  longitudinal 
incision  being  afterwards  stitched  up  transversely  , 
aT'iit  the  ordinary  operation  of  pyloroplasty.  In 
another  case  under  the  care  of  a  colleague  a  pedun- 
culated adenoma  the  size  of  a  cherry  acting  like  a 
ball-valve  produced  similar  symptoms^  which  were 
cured  by  its  removal. 

When  the  tumour  is  large  it  may  form  a  freely- 
movable  epigastric  tumour  as  in  a  case  reported  by 
Sutton^  and  in  another  reported  by  Dr.  Hinds. 

The  symptoms  may  resemble  those  of  cancer  by 
inducing  coffee-ground  vomiting  and  wasting  as  in 
a  case  reported  by  Cliaput  at  the  Societe  de 
Chirurgie^  in  l^iris^  1894.  The  patient  was  a  man, 
aged  sixty-four  years.  The  symptoms  were  chiefly 
emaciation  and  vomiting  of  coffee-ground  material,  and 
an  epigastric  tumour  was  observed.  At  the  opera- 
tion an  adenoma  covered  with  normal  mucous  mem- 
brane was  found  attached  by  a  small  pedicle  to  the 
posterior  wall  of  the  stomach. 

Adenoma  may  pass  on  into  carcinoma  or  be 
associated  with  it,  as  in  a  specimen  noAv  in  the 
Leeds  Museum. 

Hay  em  described  two  cases  in  which  the  growth 
resembled   Brunner's  glands. 

Ebstein  collected  twenty-four  cases  of  mucous 
polypi,    fifteen  in  men  and  eight  in  women,   in  one 


PLATE    X. 


Polypi  growing  troni  the  mucous 
membrane  of  the  stomach  of  a 
gentleman,  seventy-six  years 
of  age,  who  suffered  from  con- 
stant dyspepsia. 

(No.   2405,  Royal  College   of 
Surgeons'  Museiun.) 


~ isi— ^ 


Polypus  near  pylorus  which  caused 
fatal  intussusception  of  duodeniim  in 
a  man  aged  twenty-one. 

(No.  2405c,  Eoyal  College  of  Surgeons' 
Museum.) 


To  f lire  p.  100. 


Adlarrl  j-  Sou,  I^npr. 


SIMPLE   TUMOURS  OF   THE    STOMACH  101 

the  sex  not  being  mentioned.  He  stated  that  the 
frequency  of  these  tumours  increases  after  forty 
years  of  age;  in  one  half  the  tumours  were 
solitary,  in  the  rest  multiple,  even  up  to  200  in 
number. 

The  mucous  membrane  over  them  may  be  smooth 
or  villous. 

Treatment. — When  adenoma  is  polypoid  it  should 
be  removed  and  the  pedicle  ligatured.  If  forming 
a  sessile  tumour  it  should  be  freely  excised  and  the 
healthy  edges  of  mucous  membrane  and  stomach 
wall  brought  together  by  suture. 

If  the  pylorus  be  invaded  by  a  sessile  adenoma 
the  growth  should  be  freely  excised  and  a  gastro- 
enterostomy performed,  but  if  the  deeper  layers  of 
the  stomach  wall  are  invaded,  pylorectomy  or  partial 
gastrectomy  should  be  performed. 

Lymphadeiioma. — This  is  a  rare  form  of  tumour 
characterised  by  the  appearance  of  multiple  polypoid 
projections  into  the  cavity  of  the  stomach. 

Pitt  (2)  stated  that  he  had  only  been  able  to  find 
seventeen  cases  recorded  in  literature. 

The  neoplasm  usually  arises  in  the  mucous  mem- 
brane or  in  the  submucosa,  but  it  may  arise  in  the 
serous  coat  of  the  stomach. 

In  the  special  case  reported  by  Pitt  the  disease 
was  evidently  maliguant  and  had  invaded  other 
viscera. 

In  a  case  reported  by  Normans  (3)  symptoms  were 


102  CANCER   OF   THE   STOMACH 

absent^  altliongli  tlie  mucous  membraue  of  the 
stomacli  was  everywliere  covered  by  dendriform 
projections  and  wart-like   growtlis. 

The  projections  may  ulcerate  and  give  rise  to 
severe  liEematemesis. 

In  the  cases  recorded  by  Cornil  and  Eanvier  (11) 
the  tumours  formed  in  the  deep  mucosa  or  in  the 
submucosa  and  sent  prolongations  into  the  outer 
coats  of  the  stomach.  This  condition  is  practically 
only  of  pathological  interest. 

Myoma. — Tumours  resemblino:  uterine  myomata 
histologically  may  spring  from  the  muscular  coat  of 
the  stomach  and  push  the  mucous  membrane  before 
them,  projecting  into  the  stomach  as  sessile  or  poly- 
poid tumours,  or  pressing  towards  the  serous  surface 
they  may  project  into  the  abdomen  and  form  immense 
tumours^  as  in  von  Erlach's  case,  in  which  a  tumour 
Aveighing  5 4  kilogrammes  was  removed  successfully 
from  the  anterior  Avail  of  the  stomacli  (4)  and  in 
von  Eiselberg's  case,  in  Avhich  a  fibro-mj^oma  the 
size  of  a  man^s  head  Avas  successfull}^  removed  from 
the  greater  cmwature  of  the  stomach. 

Of  nineteen  cases  reported,  eleven  AA^ere  external, 
six  internal,  and  in  tAA^o  details  are  not  given. 

If  occurring  near  the  pylorus,  obstruction  may  be 
produced  as  in  Herhold^s  (5)  case,  or  they  may  ulcerate 
and  give  rise  to  ha3matemesis. 

The  treatment  of  these  tumours  is  by  remoA^al,  and 
as   they  are  benign  it  is  unnecessary  to  take  aAvay 


SIMPLE   TUMOURS   OF   THE   STOMACH  103 

more  of  tlie  wall  of  the  stomach  than  necessary  for 


removal  of  the  tumour. 


'I. 


Lipoma. — Lipomata  in  the  stomach  wall  are  ex- 
tremely rare ;  they  may  arise  from  the  submucous 
tissue  and  project  into  the  cavity  of  the  stomach,  or 
from  the  subserous  coat  and  project  into  the  peri- 
toneal cavity. 

In  Virchow's  work  [Die  Kranhhaft.Geschivuhte) 
is  figured  a  lipoma  arising  in  the  submucous  tissues 
near  the  pylorus. 

If  diagnosed,  these  tumours  can  be  readily  re- 
moved by  enucleation. 

A  case  of  lipo-myoma  has  been  reported  by  Kunze(6), 
who  removed  it  from  a  man  aged  fifty-two  years,  it 
having  been  diagnosed  as  a  mesenteric  tumour. 

Cysts. — Small  cysts  from  obstruction  of  gland  ducts 
are  not  uncommon.  Ruysch  (7)  described  a  gastric 
dermoid  c^^st  containing  hair.  Engel  Reimers  des- 
cribed a  multilocular  lymphangioma  of  the  stomach 
wall  occurring  beneath  a  chronic  gastric  ulcer  of  the 
lesser  curvature  [ibid.).  Albers  mentions  a  cyst  2\\n. 
long  on  the  lesser  curvature  of  the  stomach  in  a  child. 
Ziegler  performed  laparotomy  for  a  cyst  of  the 
stomach  following  injury ;  it  formed  a  tumour  for 
which  the  operation  was  undertaken,  and  after 
emptying  the  cyst  it  did  not  refill. 

Mr.  Jonathan  Hutchinson  (8)  described  a  cj^stic 
tumour  the  size  and  shape  of  a  walnut,  situated  near 
the  pylorus  between  the  muscular  and  mucous  coats. 


104  CANCER    OF   THE   STOMACH 

Anderson  (9)  described  multiple  cysts  of  the  stomach 
and  intestines  which  he  believed  originated  from  in- 
clusion or  embryonal  rests  after  the  manner  of 
dermoids. 

^  H.  Eead  (10)  described  a  case  of  a  man,  aged  sixty- 
two  years,  who  died  after  an  illness  of  five  weeks,  and 
at  autopsy  a  cyst  was  found  comj^letely  encircling 
the  stomach.  It  contained  clear  fluid  and  a  fatty 
substance  with  black  streaks  of  extravasated  blood. 

REFERENCES. 

1.  Ebstein. — Arch.  p.  Ajiat.  a  Physiol.,  1864. 

2.  Pitt.— Poi/i.  Soc.  Trans.,  1899. 

3.  Normans. — Dublin  Journ.  of  Med.  Sci.,  vol.  xcv. 

4.  Yon  Erlach.— TT^ie?i.  Min.  Woch.,  1895,  No.  15. 

5.  Herhold. — Deutsche  med.  Woch.,  1898,  vol.  iv. 

6.  Kunze. — Annals  of  Univ.  Med.  Sci.,  1891. 

7.  Ruysch. — Hemmeter,  p.  569. 

8.  Hutchinson,  Jonathan.— Pai?i.  Soc.  Trans.,  1857. 

9.  Anderson.— Brif.  3Ied.  Journ.,  1898. 

10.  Read,  K.—Med.  Record,  1882. 

11.  Cornil  and  Ranvier.— iHa««aZ  de  VHistolog.  Path.,  p.  294. 


CHAPTER    VI 

SARCOMA  OF  THE  STOMACH 

Peimary  gastric  sarcoma  is  not  so  rare  as  it.  is 
generally  tliouglit  to  be.  It  is  probable  tliat  a  num- 
ber of  cases  described  as  cancer  have  been  truly 
sarcoma;  this  we  may  conclude  from  the  fact  that  a 
number  of  museum  specimens  classed  as  cancer  have 
on  microscopic  examination  proved  to  be  sarcoma. 

Fenwick  (5)  stated  in  ^fe$S»fe«q««$#@^^  that  out  of 
sixty  recorded  cases^  hfty-three  at  J  east  ought  to  be 
rcuanU'd  as  genuine^  and  he  thought  that  they 
constituted  from  5  to  8  per  cent,  of  all  primary 
neoplasms  of  the  stomach. 

The  recognised  varieties  are  round- celled,  spindle- 
celled,  myo-sarcoma,  and  angio-sarcoma. 

Round-celled  sarcoma  constitutes  62  per  cent,  of 
all  the  recorded  cases.  It  occurs  as  a  rule  as  a  dense 
infiltration  of  the  pyloric  third  of  the  stomach,  and, 
unlike  cancer,  tends  to  render  the  pylorus  patulous, 
though  ill  some  cases  the  thickening  leads  to  partial 
stenosis.  In  about  one  sixth  of  the  cases  the  growth 
involves  the  entire  stomach,  iuvadiug  both  oesophagus 


106  CANCER    OF   THE   STOMACH 

and  duodenum.  The  mucous  membrane  presents 
sio-ns   of   chronic   inflammation    and   ulceration.      In 

o 

only  two  of  FenwicFs  cases  was  there  a  circum- 
scribed tumour  with  secondary  nodules  in  the 
surrounding  mucous  membrane.  These  growths 
have  a  tendency  to  soften  and  break  down. 

In  a  case  of  round-celled  sarcoma,  SchopE  (1)  re- 
moved a  tumour  the  size  of  a  child^s  head^  leaving 
the  cardiac  and  pyloric  ends  of  the  stomach,  which 
he  sutured  together.  The  patient  was  alive  twelve 
months  later. 

8 inndle- celled  sarcoma  constituted  22  per  cent,  of 
the  fifty-three  cases.  It  presents  itself  usually  as  a 
round  or  circumscribed  tumour  in  the  neighbourhood 
of  the  greater  curvature^  and  tends  to  project  towards 
the  serous  coat,  ultimately  forming  a  very  large 
tumour,  sometimes  becoming  pedunculated.  The  size 
attained  may  be  enormous,  so  as  to  fill  the  whole  of 
the  abdomen. 

Billroth  successfully  removed  a  cystic  sarcoma  of 
this  variety.  Cant  well  (2)  removed  one  weighing 
12  lb.,  but  it  recurred  eight  months  later. 

Myosarcoma. — Five  out  of  fifty- three  recorded 
cases  were  of  this  variety.  They  form  smooth  or 
slightly  nodular  tumours,  and  usually  occur  near  the 
greater  curvature.  They  may  attain  an  enormous 
size,  Brodowski  having  met  with  one  of  12  lb. 
They  are  apt  to  undergo  cystic  degeneration  and  to 
be  accompanied  by  severe  hoemorrhage. 


SARCOMA   OF   THE   STOMACH  107 

Angiosarcoma. — Two  cases  have  been  recorded. 
In  one  case  the  tumonr  was  the  size  of  a  child's 
head  ;  it  contained  many  cysts  due  to  ha3morrhage. 
Kosinski  (3)  successfully  removed  a  tumour  of  this 
kind. 

Symptoms. — Sarcoma  of  the  stomach  may  occur  at 
any  time  of  life,  from  infancy  to  extreme  old  age.  The 
symptoms  are  similar  to  those  of  carcinoma — progres- 
sive loss  of  flesh  with  debility  and  anaemia.  Pain  is 
usually  present.  Pyrexia  slight,  but  persistent. 
Albumen  in  the  urine  may  be  present.  Haematemesis 
is  apt  to  occur  and  may  be  so  free  as  to  cause  death. 
Free  HCl  is  usually  absent  and  lactic  acid  present  as 
in  cancer.  The  small  round-celled  sarcoma  resembles 
cancer  in  all  respects  except  in  less  frequently  lead- 
ing to  stenosis ;  but  in  spindle-celled  sarcoma  gastric 
symptoms  maybe  entirely  absent,  and  wheu  operative 
treatment  is  undertaken  in  a  rapidly-growing  tumour 
the  growth  may  be  discovered  unexpectedly  to  be 
arising  from  the  stomach.  Perforation  is  apt  to  occur 
in  round-celled  sarcoma  in  from  10  to  12  per  cent,  of 
all  cases.  Metastases  in  glands,  in  distant  organs, 
and  especially  in  the  skin,  are  prone  to  occur.  Ac- 
cording to  Kundrat,  the  tonsils  are  apt  to  enlarge 
and  the  follicles  on  the  side  of  the  tongue  to  become 
swollen  and  ulcerated. 

The  prognosis  varies  with  the  nature  of  the  growth; 
in  round-celled  sarcoma  the  average  duration  of  life 
is    fifteen    months ;     in    spindle-celled    sarcoma    and 


108  CANCER   OF   THE   STOMACH 

myo-sarcoQia  tlie  avercage  is  two  years  and  eiglit 
months. 

Treatment. — Surgical  treatment  of  gastric  sarcoma 
lias  met  witli  considerable  success  so  far  as  tlie  im- 
mediate effect  of  operation  is  concerned.  The  solid 
tumours  are  especially  favourable  for  extirpation, 
especially  wIk'u  pi'dunculated,  but  in  all  cases  it  is 
desirable  to  remove  the  portion  of  stomach  Avail  from 
which  they  spring  very  freely. 

In  the  round-celled  variety  a  wide  removal  of  the 
stomach  by  partial  or  conijik'te  gastrectomy  is  re- 
quired in  order  to  give  any  hope  of  success.  Torek, 
Dock,  Schopf,  and  others  have  removed  considerable 
tumours,  and  in  Schopf's  case  the  patient  was  living 
a  year  later. 

Early  diagnosis  and^arly  thorough  surgical  treat- 
nient  must  be  the  great  aims  in  the  treatment  of 
sarcoma. 

Statistics. — Lecene  and  Petit  (4)  report  ten  deaths 
out  of  twenty-four  collected  cases,  but  only  one  out 
of  seven  proved  fatal,  where  the  resection  of  the 
gastric  walls  was  around  a  circumscribed  tumour. 

REFERENCES. 

1.  Schopf.-Ceni)-./.  Chir.,  1899,  p.  1163. 

2.  Cantwell. — Annals  of  Surgery,  1899,  vol.  ii,  p.  596. 

3.  Kosinski. — Deutsch  Gesellsch.f.  Chir.,  1892. 

4.  Lecene  and  Petit. — "  La  Sarcome  Primitif  de  TEstomac,"  Rev. 
de  Gyn.  et  de  Chir.,  Abel.  November  and  December,  1904,  p.  965. 

5.  Fenwick. —  Cancer  and  Tumours  of  the  Stomach. 


CHAPTER   VII 
DILATATION  OF  THE  STOMACH 

Dilatation  of  tlie  stoniacli  may  be  acute  or  cliroiiic. 
The  acute  condition  constitutes  a  distinct  disease^,  and 
is  seldom  if  ever  associated  with  cancer  of  the  organ. 

Chronic  dilatation  may  be  obstructive  or  atonic. 
As  a  sequence  of  cancer  of  the  pylorus  or  pyloric 
eud  of  the  stomach  obstructive  dilatation  is  quite  of 
common  occurence,  and  calls  for  treatment,  whereas 
simple  atonic  dilatation,  though  sometimes  associated 
with  cancer,  seldom  calls  for  surgical  treatment. 

Obstructive  dilatation. — Although  dilatation  of  the 
stomach  has  been  recognised  for  centuries  as  a 
pathological  entity,  its  full  importance  was  not 
appreciated  until  the  latter  fourth  of  the  nineteenth 
century,  when  Kussmaul  and  his  pupils  began  to 
consider  the  effects  of  obstruction  on  the  functions 
of  digestion. 

The  causes  of  mechanical  dilatation  of  the  stomach 
are  usually  at  or  near  the  pylorus  or  in  the  duodenum, 
and  may  be  due  to  malignant  or  non-malignant  dis- 
ease.     They  are  : 


110  CANCER   OF   THE    STOMACH 

{a)  Cancer  of  tlie  pylorus. 

{h)   Cancer  of  the  duodenum. 

(r)    Rarely  sarcoma  of  the  pylorus  or  duodenum. 

{d)  Cancer  of  the  body  of  the  stomach  leading  to 
hour-glass  stricture  and  dilatation  of  the  cardiac 
portion  of  the  stomach. 

Other  causes  leading  to  dilatation  of  the  stomach, 
and  which  may  be  therefore  important  from  a  dia- 
gnostic point  of  view,  are  : 

(d)  Stenosis  of  the  pylorus  due  to  contraction  of 
a  simple  ulcer. 

{b)  Hour-glass  stricture  of  the  stomach  from  con- 
traction due  to  simple  ulcer,  leading  to  dilatation  of 
the  cardiac  jDOucli. 

(c)  Perigastritis,  leading  to  stricture  or  to  kink  of 
the  pylorus. 

(d)  Hypertrophy  of  the  pylorus  with  fibroid 
thickening,  occasionally  seen  in  adults,  but  more 
frequently  found  in  infants,  when  it  is  known  as 
"  congenital  hypertrophic  stenosis.''^ 

(e)  Pyloric  spasm,  a  secpiel  of  gastric  ulcer,  which 
may  continue  long  after  the  ulcer  has  healed. 
Spasm  of  the  pylorus  is  also  a  symptom  of  severe 
hyperchlorhydria,  when  it  is  known  as  Reichmann^s 
disease. 

(/)   Polypus  at  the  pyloric  end  of  the  stomach. 
{g)   Tumour  outside  the  pylorus  pressing  on  and 
obstructino-  it. 

o 

{h)  Pressure   on    the   duodenum    by  an   abnormal 


DILATATION    OF   THE   STOMACH       111 

enlargement  of  tlie  pancreas,  as  when  the  inflamed 
head  of  the  pancreas  embraces  the  duodennm_,  or 
when  growth  of  the  pancreas  invades  it. 

(^)  Pressure  by  the  mesenteric  vessels  as  they 
cross  the  duodenum. 

(j)  Cholelithiasis  producing  ulceration  and  inflam- 
matory thickening  of  the  pylorus  and  first  part  of  the 
duodenum. 

(h)  Kink  of  the  pylorus  due  to  the  dragging  by  a 
movable  right  kidney. 

(/)   Kink  of  the  pylorus  due  to  gastroptosis. 

Diagnosis. — The  diagnosis  of  cancer  from  other 
conditions  leading  to  dilatation  is  fully  considered  in 
the  chapter  dealing  with  diagnosis  generally. 

Symptoms. — The  first  effect  of  stenosis  when  not 
sufficient  to  produce  complete  obstruction  is  to  cause 
increased  peristalsis  in  order  to  overcome  the  ob- 
struction. When  the  health  is  otherwise  good  this 
compensatory  hypertrophy  enables  a  moderate  degree 
of  obstruction  to  be  overcome.  As  soon,  however,  as 
compensation  fails,  retention  of  food  and  of  the  gas- 
tric secretion  takes  place.  Fermentation  of  the 
retained  contents  then  follows,  leading  to  sub-acute 
gastritis  or  catarrh,  the  first  result  of  which  is  to 
weaken  the  muscular  wall  of  the  stomach.  For  a 
time  relief  may  be  obtained  by  vomiting,  which  takes 
place  at  irregular  intervals.  Early  in  the  history  of 
dilatation  vomiting  may  only  occur  every  second  or 
third  day,  but  as  the  obstruction  increases  it  occurs 


112  CANCER   OF   THE   STOMACH 

daily,  and  ultimately  may  take  place  after  every  meal. 
As  the  result  of  tliese  pathological  changes  wasting 
occurs,  and  as  less  and  less  fluid  becomes  absorbed 
from  the  diseased  stomach  there  is  great  thirst,  in- 
creasing constipation,  and  diminished  excretion  of 
urine ;  and  when  the  obstruction  finally  becomes 
complete  death  occurs  from  starvation. 

According  to  the  extent  of  the  ulceration  and  the 
amount  of  cicatricial  contraction  the  symptoms  may 
be  hastened  or  delayed,  so  that  in  some  cases  months 
or  even  years  may  pass  before  the  final  stage  is 
reached  if  the  disease  be  simple ;  but  it  must  be 
borne  in  mind  that  cancer  may  be  grafted  on  chronic 
ulcer.  The  length  of  time  that  symptoms  have  been 
present  does  not,  therefore,  exclude  the  possibility  of 
cancer. 

The  various  forms  of  pyloric  obstruction  mentioned 
under  the  different  causes  do  not  all  pursue  so  slow  a 
course.  For  instance,  the  inflammation  dependent  on 
pyloric  or  duodenal  ulcer  may  be  so  acute  as  to  cause 
great  swelling  that  may  rather  acutely  block  the  out- 
let of  the  stomach,  and  the  supervention  of  spasm 
may  lead  to  an  acute  exacerbation  of  symptoms  pre- 
viously chronic. 

In  considering  the  clinical  history,  it  is  necessary 
therefore  to  take  into  consideration  the  cause  of  the 
stenosis,  and  secondly  the  symptom  due  to  dilatation 
l^er  se. 

After   an    ordinary  meal  the    stomach    should    be 


DILATATION    OF   THE    STOMACH       113 

found  empty  in  about  six  or  seven  hours.  If  the 
motor  functions  of  tlie  stomach  are  impaired  the 
remains  of  food  will  be  found  later  than  this  :  for 
instance,  when  the  dilatation  is  well  marked  and  the 
stomach  is  washed  out  early  in  the  morning-,  the  re- 
mains of  the  supper  of  the  previous  evening  may  be 
found  in  it.  If  the  obstruction  is  not  complete,  and 
there  is  a  certain  amount  of  muscular  power  in  the 
gastric  walls,  the  patient  may  only  complain  of  a 
sense  of  weight  and  discomfort  in  the  epigastrium, 
and  of  flatulency.  In  well-marked  cases  visible 
peristalsis  from  left  to  right  is  seen — a  symptom 
which  is  almost  pathognomonic  of  mechanical  ob- 
struction, and  in  such  cases  vomiting  will  almost 
certainly  be  a  prominent  symptom.  The  vomit  in 
obstructive  dilatation  is  quite  characteristic,  in  that 
it  is  large  in  amount  and  characterised  by  the  presence 
of  well-marked  fermentation.  It  may  contain  par- 
ticles of  food  that  have  been  taken  days  before.  If 
allowed  to  stand  the  vomit  will  usually  separate  into 
three  layers,  a  sediment  consisting  of  solid  particles 
of  food,  a  central  layer  of  dirty  greyish  fluid,  and  a 
scum  of  frothy  fermenting  material,  in  which  will  be 
found  yeast  cells  and  sarcin^e.  In  quite  a  number 
of  cases  of  gastrectasis  from  simple  pyloric  stenosis, 
tetany  in  a  greater  or  less  degree  is  a  marked  sym- 
ptom, which  may  even  lead  to  a  fatal  issue.  A 
physical  examination  before  the  stomach  has  emptied 
itself   will   usually   yield   a    well-marked    succussion 

8 


114  CANCER   OF   THE    STOMACH 

splash,  and  on  distending  the  stomach  with  carbonic 
acid  gas  or  air,  gastric  resonance  may  be  fonnd  in 
severe  gastrectasis  to  reach  to  the  pelvis ;  bnt  even 
when  the  dilatation  is  onl}'  moderate  in  extent  the 
stomach  will  usually  reach  well  below  the  umbilicus. 

In  rare  cases  of  simple  stenosis,  a  tumour  may  be 
felt^  but^  as  a  rule^  in  stenosis  from  ulcer,  the  pylorus  is 
fixed  by  adhesions  under  cover  of  the  liver_,  and  unless 
the  thickening  is  considerable  it  is  difficult  to  discover 
any  tumour  on  palpation.  A  palpable  tumour,  espe- 
cially if  it  be  freely  movable,  is  more  likely  to  be  due 
to  cancer  than  ulcer^  though  this  rule  is  not  absolute. 

Hyperchlorhydria  is  usually  present  in  simple 
cicatrical  stenosis,  though  if  the  dilatation  has 
existed  for  a  long  time  the  peptic  glands  may  be 
seriously  damaged  and  free  HCl  may  be  absent,  as 
it  usually  is  in  malignant  disease. 

Where  there  is  a  chronic  ulcer,  blood  may  be  found 
on  microscopic  examination,  but  coffee-ground  vomit- 
ing^ is  less  characteristic  of  this  form  of  stenosis  than 
when  the  dilatation  is  dependent  on  cancer. 

Pain  is  usually  present  at  some  stage  of  the 
disease.  It  may  vary  with  the  cause  :  for  instance, 
if  from  ulcer  at  the  pylorus  it  usually  occurs  two  to 
three  hours  after  a  meal,  and  may  be  relieved  b}^ 
food  in  the  earlier  stages ;  if  from  cancer  there  may 
be  little  pain  for  a  time  ;  but  as  the  disease  pro- 
gresses, painful  peristalsis  may  occur  at  irregular 
intervals  and  may  be  increased  by  food. 


DILATATION   OF   THE    STOMACH       115 

Wlien  the  dilatation  becomes  extreme  there  may  be 
merely  a  sense  of  weight  and  fulness  due  to  the  ac- 
cumulation of  food^  secretions^  and  flatus_,  which  may 
be  relieved  by  vomitiug  or  by  lavage  of  the  stomach. 

The  final  stages  are  characterised  by  subnormal 
temperature,  coldness  and  lividity  of  the  extremities, 
and  extreme  loss  of  strength,  ending  in  death  from 
exhaustion . 

Treatment. — In  the  early  stages  of  obstructive 
dilatation  when  the  symptoms  are  slight,  relief  for 
a  time  will,  doubtless,  have  been  given  by  lavage  of 
the  stomach  and  the  observance  of  a  strict  diet ; 
but  as  soon  as  the  symptoms  are  pronounced  it  is  a 
mere  waste  of  time  to  persevere  Avith  the  use  of  drugs, 
massage,  electricity,  or  even  lavage,  except  iu  those 
rare  cases  where  the  stenosis  is  due  either  to  syphi- 
litic ulcer  or  gumma,  which  should  speedily  respond 
to  specific  treatment. 

Surgical  treatment  is  alone  of  avail  in  order  to 
remove  the  cause  of  the  stenosis  or  to  create  a  new 
channel  by  which  the  stomach  contents  may  pass 
onwards  into  the  intestines. 

It  may  sometimes  be  possible  to  remove  the  cause 
of  the  stenosis  by  division  of  peritoneal  bands  or 
adhesions,  or  the  removal  of  a  tumour  obstructing 
the  pylorus,  but  in  the  majority  of  cases  of  cancer 
it  will  be  necessary  either  to  do  a  partial  gastrectomy 
or  to  perform  a  gastro-enterostomy. 

Pylorectomy    or    partial    gastrectomy  is    a    much 


116  CANCER   OF   THE    STOMACH 

more  severe  procedure  tliaii  gastro-enterostom}^,  but 
there  is  a  certain  class  of  cases  in  wliicli  it  is  difficult 
to  say  whether  the  disease  is  simple  or  malignant. 
If  malignant^  partial  gastrectomy  including  the 
pyloric  orifice  should  certainly  be  performed  if 
the  disease  is  not  too  extensively  involving  the 
lymph-glands   or  associated  with  secondary  growths. 

If  the  obstruction  of  the  pylorus  is  associated 
with  a  tumour  due  to  inflammatory  disease^  in  all 
probability  it  will  be  so  adherent  to  the  under 
surface  of  the  liver  or  to  the  pancreas  that  pylo- 
rectomy  will  be  extremely  difficult  and  hazardous.  In 
such  cases  it  will  probably  be  deemed  necessary  to 
rest  content  with  gastro-enterostomy  in  the  hope 
that  the  rest  induced  by  the  operation  will  cause  a 
subsidence  of  the  tumour.  I  have  found  this  to 
apply  in  many  such  cases  in  which  at  the  time 
there  was  a  question  of  malignant  disease. 

If,  however,  under  these  circumstances  the  tumour 
should  be  free  from  adhesions  and  the  disease  limited 
to  the  neighbourhood  of  the  pylorus,  it  may  be  quite 
justifiable  to  perform  pylorectomy  in  case  of  doubt. 


CHAPTER    VIII 
OPERATIONS  FOR  GASTRIC  CANCER 

(1)  Simple  exploratory  incision. 

(2)  Gastrectomy.      (a)   Partial. 

{h)   Complete. 

(3)  Gastro-enterostomy. 

(4)  Gastrostomy. 

(5)  Jejunostomy. 

Exploratory  incision. — Altliongli  exploratory  incision 
for  the  purpose  of  making  a  diagnosis  is_,  as  a  rule, 
undesirable,  in  certain  cases  tlie  operation  is  not  only 
justifiable  but  strongly  to  be  urged.  Wlienever 
cancer  of  the  stomach  is  suspected  and  the  diagnosis 
cannot  be  verified  by  ordinary  methods,  an  explora- 
tory operation  should  be  urged,  for  it  has  been  clearly 
proved  that  in  the  surgical  treatment  of  cancer  the 
earlier  an  operation  can  be  performed  the  greater 
will  be  the  chance  of  radical  cure,  whereas  if  a  dia- 
gnosis of  the  disease  be  not  made  until  a  tumour  can 
be  felt  by  palpation,  it  is,  as  a  rule,  too  late  for 
radical  treatment. 


118  CANCER   OF   THE    STOMACH 

An  exploratory  operation  may  also  be  required  in 
certain  cases  of  palpable  tumour  of  tlie  stomacli  in 
wliicli  it  is  just  possible  that  tlie  growth  may  be 
amenable  to  surgical  treatment^  but  where  it  cannot 
be  said  beforehand  whether  the  lymphatic  glands  are 
too  extensively  involvecl_,  or  the  disease  has  so  far  in- 
vaded the  adjoining  tissues  that  removal  of  the  growth 
would  be  useless_,  Avhen  a  gastro-enterostomy  or  a 
jejunostomy  may  have  to  be  performed  as  palliative 
procedures. 

In  some  other  diseases  and  injuries  of  the  stomacli 
it  is  found  impossible  to  say  what  operation  or  opera- 
tions may  be  required  before  the  abdomen  is  opened 
and  the  extent  and  nature  of  the  disease  ascertained 
by  inspection  and  palpation.  Every  operation  on  the 
stomach  therefore_,  in  this  sense^  is  an  exploratory 
jDrocedure^  and  the  surgeon  must  be  prepared  to 
adapt  himself  to  circumstances  when  he  sees  the 
nature  and  extent  of  the  disease. 

Operation. — If  there  is  time  to  prepare  the  patient 
it  is  desirable  that  the  condition  of  the  mouth  should 
be  attended  to_,  and  that  aseptic  foods  should  be  given 
for  forty-eight  hours  before  operation.  To  this  end 
I  am  accustomed  to  recommend  patients  to  wash  their 
teeth  with  a  1  per  cent,  solution  of  carbolic  acid 
several  times  daily  for  two  days  before  operation.  I 
also  direct  that  nothing  but  food  that  can  be  steri- 
lised by  boiling  or  cooking  should  be  giveu^  and  that 
the   plates    on    which   it  is  served,  and   the  utensils 


OPERATIONS   FOR   GASTRIC    CANCER    119 

used^  sliould  all  be  sterilised  by  boiling  water  before 
use. 

Except  in  cases  o£  marked  retention  of  tlie  stoniacli 
contents  I  am  not  accustomed  to  liave  tlie  stomacli 
washed  out  before  operation,  unless  the  patient  has 
been  accustomed  to  it^  and  can  submit  to  it  without 
inconvenience;  but  if  there  is  retention  of  the  stomach 
contents,  as  in  many  cases  of  pyloric  stenosis,  I  some- 
times have  the  stomach  washed  out  night  and 
morning  the  day  before  operation.  No  food  is  given 
on  the  morning  of  operation,  but  a  pint  of  saline 
fluid,  with  1  oz.  of  liquid  pej3tonoids  and  1  oz.  of 
brandy,  is  given  by  rectum  about  half-an-hour  before. 
I  usually  order  a  dose  of  castor  oil  to  be  given  two 
nights  before,  to  be  followed  by  an  enema  the  night 
before  the  operation  is  arranged,  thus  avoiding  the 
necessity  of  disturbing  the  patient  later.  As  it  is 
important  that  the  patient  should  be  depressed  as 
little  as  possible  by  cold,  I  have  him  enveloped  in  a 
loose  gam  gee  tissue  suit,  which  can  be  readily  run 
together  by  the  nurse  in  an  hour  or  two.  The  skin 
of  the  abdomen  and  lower  thorax  is  thoroughly 
washed  with  soap  and  water  the  day  before  opera- 
tion, and  a  1  in  1000  solution  of  biniodide  of  mercury 
in  70  per  cent,  alcohol  is  applied  on  lint,  Avhich  is 
then  covered  with  jaconet  or  oiled  silk  and  fixed  by 
a  bandage,  the  dressing  being  changed  and  re- 
applied on  the  morning'  of  operation. 

The    stomach   is   exposed    by    a   vertical    incision 


120  CANCER   OF   THE    STOMACH 

made  an  incli  to  the  riglit  of  the  mid-line  from  a 
point  a  little  below  the  ensiform  cartilage  downwards 
to  the  level  of  the  nmbilicns.  The  anterior  rectus 
sheath  is  incised  to  the  same  extent^  and  then  the 
rectus  is  either  retracted  externally  or  the  muscle  is 
split,  after  which  the  posterior  rectus  sheath  and 
peritoneum  are  divided  to  the  same  extent.  I  prefer 
this  incision  to  the  one  in  the  mid-line,  as  the  latter 
forms  a  less  secure  scar,  and  is  inconvenient  in  case 
the  incision  has  to  be  prolonged ;  moreover,  the  round 
ligament,  with  its  irregular  adipose  envelope,  is  apt 
to  be  in  the  way. 

Should  operative  measures  demand  an  extension 
of  the  incision,  it  can  be  prolonged  as  far  as  necessary 
without  weakening  the  abdominal  wall,  as  no  muscle 
is  divided  in  the  process.  The  stomach  is  now  ex- 
posed and  the  whole  of  the  anterior  surface  can  be 
seen  by  retracting  the  margins  of  the  incision  and 
raising  the  lower  border  of  the  liver.  If  the  posterior 
wall  of  the  stomach  has  to  be  examined,  the  great 
omentum  and  the  transverse  colon  should  be  brought 
out  of  the  wound,  and  a  vertical  incision  is  then 
made  throuo-h  the  transverse  meso-colon,  throug-h 
which  the  fingers  can  be  passed  so  as  to  explore  the 
whole  of  the  posterior  gastric  wall. 

This  will  end  the  exploratory  abdominal  section 
qua  exploration,  but  if  needful  any  further  opera- 
tion can  then  be  proceeded  with. 

Should  nothing  further  be  required,  the  abdomen 


OPERATIONS   FOR   GASTRIC   CANCER    121 

is  closed  by  a  continuous  suture  of  No.  3  iodised  cat- 
gut, tlie  peritoneum  and  posterior  aponeurosis  being 
first  united,  the  suture  returning  along  tlie  anterior 
aponeurosis  till  it  reaches  the  point  where  the  stitch- 
ing was  begun,  after  which  the  two  ends  of  catgut 
are  tied  and  cut  short.  In  order  to  strengthen  the 
line  of  sutures  two  or  three  interrupted  sutures  of 
No.  2  lightly  chromicised  catgut  are  passed  through 
and  through  the  aponeurosis  and  muscle  and  drawn 
just  tight  enough  to  approximate  all  the  layers,  but 
not  so  tight  as  to  endanger  the  tissues  being  strangu- 
lated, after  which  the  edges  of  the  incision  are 
brought  together  by  Michel's  metal  sutures.  Aseptic, 
dry,  double  cyanide  gauze  is  then  applied,  and  over 
this  aseptic  wool,  strapping,  and  a  many-tailed  band- 
age, care  being  exercised  not  to  compress  the  lower 
thorax  unnecessarily. 

When  performed  for  cancer,  the  incision  need  not 
be  larger  than  to  admit  two  fingers,  as  it  is  easy 
to  extend  it  should  that  be  necessary  for  more  thorough 
exposure  of  the  stomach.  It  may  be  performed  under 
local  anaesthesia  if  thought  necessary,  but  as  a  rule  a 
general  anaesthetic  is  desirable. 

If  no  disease  of  the  stomach  be  found,  the  small 
incision  can  be  securely  closed,  and  the  patient  may 
safely  be  allowed  on  the  sofa  within  the  week. 

If  the  disease  is  found  too  extensive  for  removal  and 
no  further  operation  be  required,  it  is  most  desirable 
that   the  few  remaining  weeks   of  life  should  not  be 


122  CANCER    OF   THE    STOMACH 

spent  in  bed,  and  if  the  aponeurosis  and  muscles  are 
united  by  buried  tlirougli-and-tlirougli  silver  sutures 
or  by  silkworm-gut  sutures,  and  tlie  Avound  covered 
with  a  collodion  dressing,  the  patient  may  safely  be 
allowed  on  the  couch  on  the  second  or  third  day. 
The  risks  of  an  exploratory  operation  for  diagnostic 
purposes  in  an  early  stage  of  disease  are  practically 
nil,  and  in  efficient  hands  are  only  likely  to  occur 
from  some  accidental  cause,  such  as  pneumonia  or 
pulmonary  embolism. 

In  the  later  stages,  when  there  is  tumour  and  the 
disease  is  too  advanced  for  removal,  the  risk  is,  of 
course,  greater,  and  depends  on  the  condition  of  the 
patient  rather  than  on  the  operation. 

Kronlein  had  a  mortality  of  9'5  joer  cent,  in  seventy- 
three  cases,  four  from  exhaustion,  two  from  pneu- 
monia, and  one   from  pulmonary  embolism. 

Von  Mikulicz  had  four  deaths  in  forty-four  cases 
— 9  per  cent.,  and  the  duration  of  life  after  operation 
averaged  four  months. 

As  these  statistics  include  cases  operated  on 
several  years  back,  needless  to  say  they  show  a  much 
higher  rate  of  mortality  than  would  a  corresponding 
number  of  cases  operated  on  to-day.  Arguing  from 
my  own  cases  the  mortality  should,  I  think,  not 
exceed  from  2  to  3  per  cent.  In  the  St.  Mary^s 
Hospital  (Rochester,  U.S.A.)  report  for  1905,  the 
brothers  Mayo  record  twenty-five  exploratory  opera- 
tions  for    carcinoma  without    a  death,  and  in  a  later 


OPERATIONS   FOR   GASTRIC   CANCER    123 

communication  tliey  report  having  explored  the 
abdomen  in  seventy-two  patients  where  the  disease 
proved  to  be  beyond  removal^  with  one  death.  The 
average  stay  of  these  cases  in  hospital  was  less  than 
five  days. 


CHAPTER    IX 
aASTRECTOMY 

Although  so  far  back  as  1810  Merrem^  operating 
on  a  dog,  showed  the  possibility  of  a  successful 
removal  of  the  pylorus,  the  operation  was  not  per- 
formed on  man  until  April  9th,  1879,  by  Pean,  the 
first  successful  operation  being  by  Billroth,  on 
Febuary  28th,   1881. 

It  is  now  universally  recognised  that  a  radical 
operation  for  the  complete  and  wide  removal  of  the 
growth  should  be  the  aim  of  surgical  treatment  for 
cancer  or  sarcoma  of  the  stomach. 

For  gastrectomy  to  be  entirely  successful  it  is 
desirable  that  the  operation  should  be  undertaken  at 
an  early  stage  of  the  disease,  before  extensive 
adhesions  have  formed,  before  the  l^^mphatics  have 
been  seriously  invaded,  and  before  secondary  growths 
have  developed. 

The  idea  that  it  is  too  late  to  perform  a  radical 
operation  when   a   perceptible   tumour  is    present  is 


GASTRECTOMY  125 

exploded^  as  it  is  well  known  that  many  partial  and 
even  complete  gastrectomies  have  led  to  successful 
issues  in  the  presence  of  large  tumours  ;  for  instance, 
in  one  of  my  cases  the  tumour  on  removal  weighed 
a  pound,  and  the  operation  was  only  just  short  of 
total  gastrectom}^,  yet  the  patient  is  in  good  health 
over  six  years  later. 

It  should  not  be  lost  sight  of  that  the  presence  of 
enlarged  lymph-glands  does  not  necessarily  imply 
their  cancerous  invasion,  as  ulcers  alone  or  the 
inflammation  of  a  cancerous  tumour  may  cause 
glandular  enlargement  without  there  being  cancerous 
infiltration  of  the  glands ;  this  I  have  found  on 
several   occasions. 

Firm  adhesions  to  neio'libourino-  oro-ans,  liver, 
pancreas,  gall-bladder  or  colon,  or  to  the  parietes,  as 
a  rule,  forbid  a  radical  procedure,  though  in  one  of 
my  cases  the  removal  of  the  gall-bladder,  a  portion 
of  the  liver  and  the  pylorus,  as  well  as  a  considerable 
area  of  parietal  peritoneum  and  the  overlying  rectus 
muscle,  was  not  only  followed  by  recoverj^,  but  the 
patient  is  well  over  six  j^ears  later,  the  disease  having 
been  proved  to  be  cancer,  not  only  by  the  clinical 
record,  but  by  its  feel  and  appearance  and  by 
microscopic  investigation. 

If  the  tumour,  though  somewhat  tied  up  by  adhe- 
sions, is  movable,  even  if  adherent  to  the  colon,  it 
need  not  necessarily  be  given  up  as  hopeless,  as 
under   such   circumstances   a    number   of    successful 


126  CANCER   OF   THE    STOMACH 

partial  gastrectomies^  including  partial  colectomy^ 
have  been  performed.  I  have  also  successfully- 
removed  a  part  of  the  pancreas  which  was  adherent 
to,  and  apparently  infiltrated  by,  a  growth  of  the 
pylorus. 

No  good  purpose  will  be  served  by  a  gastrectomy 
that  does  not  remove  the  whole  of  the  disease,  as 
recurrence  will  be  certain  to  occur,  and  probably  as 
much  relief  with  a  very  much  diminished  risk  would 
be  given  by  a  smaller  operation. 

Partial  gastrectomy  of  the  pyloric  end  of  the 
stomach. — I  have  not  used  the  term  ^'  pylorectomy,'^ 
as  the  simple  removal  of  the  pylorus  is  only  justi- 
fiable in  non-malignant  disease,  such  as  chronic 
ulcer.  Whenever  the  disease  is  thought  to  be 
malignant  a  more  extensive  operation  must  be  done, 
involving  a  partial  excision  of  the  stomach  itself, 
including  the  pylorus  if  that  be  diseased. 

If  the  exploratory  operation  previously  described 
has  shown  the  tumour  to  be  a  removable  one, 
involving  the  pyloric  end  of  the  stomach,  the 
incision  is  extended  up  to  tlie  notch  between  the 
ensiform  cartilage  and  the  right  costal  margin  and 
doAvn  to  the  level  of  the  umbilicus  or  beyond  it. 

It  will  now  afford  some  help  if  a  small  sandbag 
be  placed  under  the  back  opposite  the  lower  ribs,  as 
in  that  way  the  area  of  operation  is  brought  close 
to  the  surface  ;  or  better  still,  a  mechanically- 
operated    table  will     accomplish   the    same    purpose 


GASTRECTOMY  127 

in  a  moment;  tlie  one  I  employ  is  known  as  the 
Guyot-Greville  table. 

The  lesser  omentum  is  divided  between  two  rows 
of  interrupted  catgut  sutures  applied  by  means 
of  a  curved  blunt  needle  in  handle,  the  ligament 
being  divided  at  a  distance  from  the  lesser  curvature 
of  the  stomach  so  as  to  include  the  glands  in  the 
part  to  be  removed. 

In  order  to  save  hemorrhage,  there  is  an  advan- 
tage, quite  early  in  the  operation,  in  ligaturing  in 
their  continuity,  or  catching  in  pressure  forceps  the 
four  arteries  with  their  accompanying  veins  supply- 
ing* the  pyloric  end  of  the  stomach ;  these  are  the 
gastric,  best  divided  at  a  point  about  f  to  1  in. 
below  the  cardiac  orifice  where  it  joins  the  lesser 
curvature  ;  the  pyloric,  just  above  the  pylorus, 
shortly  after  it  leaves  the  hepatic  artery ;  the  right 
gastro-epiploic  or  gastro-duodenal,  as  it  passes  down 
behind  the  pylorus ;  and  the  left  gastro-epiploic,  just 
below  the  greater  curvature  of  the  stomach  at  the 
point  where  the  section  of  the  stomach  is  to  be 
made.  An  aneurysm  needle  carrying  a  double 
catgut  suture  is  the  method  I  prefer,  and  the 
artery  and  vein  are  taken  up  together  and  divided 
between  the  double  ligatures. 

It  saves  time  and  answers  equally  well  to  seize 
the  four  vascular  trunks  in  pressure  forceps,  and 
when  the  excision  of  the  stomach  is  done  to  ligature 
them  singly. 


128  CANCER   OF   THE    STOMACH 

The  fingers  of  the  left  hand  are  then  passed  into 
the  lesser  peritoneal  sac  and  made  to  encircle  the 
growth  and  to  cause  the  great  omentum  to  project 
forward,  thus  avoiding  the  transverse  colic  vessels, 
the  ligature  of  which  would  endanger  the  vitality  of 
the  transverse  colon.  The  great  omentum  is  then 
ligatured  off  and  divided  in  the  same  way  as  the 
lesser,  as  wide  a  margin  of  omentum  as  possible 
being  left  attached  to  the  part  of  the  stomach  to 
be  removed. 

Double  clamps  are  then  applied  to  the  duodenum 
and  also  to  the  stomach  on  the  cardiac  side  of  the 
growth,  and  between  the  clamps  the  duodenum  is 
divided  quite  half  an  inch  on  the  distal  side  of  the 
growth  and  the  stomach  an  inch  or  more  beyond  the 
proximal  side  of  it.  The  growth,  which  is  then  free, 
is  lifted  away,  the  clamps  occluding  the  cut  ends  and 
preventing  any  of  the  contents  soiling  the  wound. 

A  careful  search  must  now  be  made  for  any  glands 
that  may  have  been  missed  and  any  such  should  be 
removed.  Any  bleeding  vessels  are  ligatured  and 
the  wound  is  cleansed  by  dry  aseptic  SAvabs. 

The  junction  of  the  stomach  and  duodenum  may 
be  carried  out  in  one  of  several  ways  : 

(1)  By  immediate  suture  of  the  open  end  of 
the  duodenum  to  the  open  end  of  the  stomach 
(Billroth)    (terminal  union). 

(2)  By  closure  of  the  stomach  opening  and 
implantation  of  the  open  end  of  the  duodenum  into 


GASTEECTOMY  129 

the  posterior  surface  of  the  stomach  (Kocher) 
(termino-lateral  union). 

(3)  By  closure  of  both  the  stomach  and  duodenal 
openings  and  the  independent  formation  of  a  gastro- 
jejunostomy (Billroth)   (lateral  union). 

(1)    By  immediate  suture    of  the   cut    ends. — This 


Fig,  6. — Partial  gastrectomy;  end-to-end  junction. 

method  was  advocated  by  Mikulicz  and  Kronlein. 
Although  statistics  seem  to  prove  that  it  is  attended 
with  greater  risks  than  the  other  methods  on  account 
of  the  fear  of  leakage  at  the  critical  angle  between 
the  vertical  and  circular  sutures,,  I  feel  sure  these 
difficulties  and  dangers  can  be  overcome  by  the  use 
of  a  continuous  suture  over  a  decalcified  bone  bobbin. 


130  CAXCER    OF   THE    STOMACH 

I  have  carried  out  the  operation  in  a  number  of  cases 
that  have  progressed  most  satisfactorily.  The  in- 
equality in  the  size  of  the  stomach  opening  is  overcome 
by  a  partial  closure  of  the  stomach  incision  so  as  to 
leave  the  gastric  opening  of  a  size  equal  to  that  in 
the    duodenum.       The   two    openings    may    then    be 


Fig.  7. — Partial  gastrectomy  ;  end-to-end  junction  by  means 
of  the  decalcified  bone  bobbin  as  a  splint  over  wliich  to 
apply  the  sutures. 

joined  either  by  means  of  sutures  or  by  sutures 
around  a  decalcified  bone  bobbin^  which  forms  a 
splint  and  ensures  the  opening  being  made  of  suffi- 
cient size.  The  bobbin  is  of  the  greatest  possible 
advantage  in  this  situation^  as  a  large  proportion  of 
deaths  that  have  occurred  from  simple  suture  have 
been  due  to  a  leakage  at  what  has  been  termed  ^Hhe 


GASTRECTOMY  131 

fatal  suture  angle  of  Billroth  ^^ — a  danger  wliicli  can 
be  wholly  avoided  by  its  use. 

Mr.  Rutherford  Morrison  advocates  the  junction 
by  simple  suture,  and  in  order  to  make  the  opening 
in  the  duodenum  correspond  in  size  with  that  in  the 
stomach  he  makes  a  slit  half  an  inch  in  length  down 
the  centi'e  of  the  anterior  wall  of  the  duodenum.  By 
spreading  out  this  longitudinal  cut  the  duodenal 
opening  is  so  Avidened  that  it  may  be  made  to  corre- 
spond in  size  with  the  stomach  opening. 

The  method  of  joining  the  cut  ends  by  suture  is 
the  same  whether  the  decalcified  bone  bobbin  is  em- 
ployed or  not ;  the  only  difference  is  that  at  a  certain 
stage  the  bobbin  is  introduced  before  the  sutures 
are  continued  around  the  anterior  half  of  the  circle. 

The  method  is  as  follows  :  While  the  clamps  are 
still  in  position  a  long  chromic  catgut  suture  is 
passed  through  all  the  coats  of  the  cut  stomach  wall, 
beginning  at  the  upper  end.  This  is  carried  down 
until  a  point  is  reached  (b)  which  will  leave  the 
stomach  opening  of  a  size  to  correspond  with  that  of 
the  duodenum.  At  this  stage  the  suture  is  passed 
beneath  the  last  loop  so  as  to  prevent  it  slipping, 
and  the  needle  is  then  temporarily  laid  aside,  still 
threaded.  The  sutured  edges  are  now  inverted,  and 
a  serous  suture,  which  only  transfixes  the  serous  and 
muscular  coat,  is  then  inserted,  commencing  at  the 
point  A  and  drawing  together  the  serous  surface  as 
far  as  the  place  where  the  marginal  suture  was  laid 


132  CANCER   OF   THE   STOMACH 

aside.      The  open  ends  of  the  tAvo  viscera  are  then 
placed  in  apposition   and  the   serous   suture  is   con- 
tinued around  the  posterior  half  circle^  uniting  the 
^Deritoneal  coats  of  the  duodenum  and  stomach  about 
a  quarter  of  an  inch  from  the  margins  of  the  opening 
that  is  to  be  permanent  between  the   stomach   and 
bowel.      The  needle  is  then  laid  aside_,  still  threaded, 
and  the  marginal  catgut  suture  previously  laid  aside 
is  now  taken  up  and  continued  around  the  posterior 
part  of  the  opening  through  all  the  coats  of  the  two 
viscera,  so  as  to  make  the  mucous  membranes   con- 
tinuous, and  at  the  same  time  to  act  as  a  haemostatic 
suture.       After    this    has    been    carried    around   the 
posterior  half  circle,  if  the  bobbin  is  employed  it  is 
now  placed  in  position  ;   but  whether  the  bobbin  is 
inserted  or  not,  the  mucous  suture  is  continued  round, 
taking  up  all  the  coats  on  the  anterior  part  of  the 
the  circle  until  it  reaches   the  point   b,  where  it  is 
secured  by  a  knot  and  cut  short.      The  serous  suture 
is  now  taken  up  and   continued  round  to  the  same 
place,  taking  up  the  serous  coats  of  the  duodenum 
and  stomach,  when  it  is  also  knotted  off  and  cut  short. 
At  the  angle  between  the  vertical  and  circular  part 
of  the  suture  there  should  be  no  point  of  danger,  and 
no  tension  if  the  stitching  has  been  Avell  done,  but  if 
there  is  any  doubt  it  may  be  advisable  to  insert  two 
or  three   separate   serous   sutures   of    Pagenstecher's 
thread  in  order  to  strengthen  this  point,  which   has 
been  termed  the  angle  of  danger. 


GASTRECTOMY  133 

(2)  KocJier^s'  method.  —  Professor  Koclier,  wliose 
method  lias  been  carried  out  most  successfully,  not 
only  by  liimself,  but  also  by  many  otlier  surgeons, 
closes  tlie  cut  end  of  the  stomach  by  means  of  a  con- 
tinuous catgut  marginal  suture,  taking  up  the  whole 
thickness  of  the   cut  surfaces,  including  the  mucous 


Fig.  S. — Partial  ^gastrectomy  ;  Koclier's  metliocb  eiicl-to-side 
junction. 


membrane,  after  which  the  united  edges  are  invagi- 
nated  and  closed  in  by  a  silk  or  Pagenstecher's 
thread  for  the  serous  surfaces.  The  open  end  of  the 
duodenum  is  then  applied  to  a  new  opening  made  in 
the  posterior  surface  of  the  stomach,  to  which  it  is 
united.  This  part  of  the  operation  may  be  accom- 
plished  either   by  simple    continuous   sutures    or   by 


134  CANCER    OF   THE    STOMACH 

sutures  around  a  decalcified  bone  bobbin.  Tlie 
junction  by  suture  or  by  suture  around  a  decalcified 
bone  bobbin  differs  in  no  way  from  the  method 
described  under  gastro-enterostomy,  except  that  in 
this  case  the  open  end  of  the  duodenum  is  applied  to 
an  incision  in  the  back  of  the  stomachy  Avhereas  in  as 
ordinary  gastro-enterostomy  the  openings  are  both 
into  the  sides  of  the  viscera  to  be  joined. 

In  some  cases  it  may  be  found  easier  to  make  the 
anastomosis  through  the  front  of  the  portion  of 
stomach  remaining  instead  of  through  the  posterior 
wall,  and  in  the  cases  on  which  I  have  made  the 
junction  by  applying  the  open  end  of  the  duodenum 
to  the  anterior  gastric  wall  the  results  have  been 
equally  good. 

(3)  The  third  method. — In  it  the  open  end  of  the 
duodenum  and  the  open  end  of  the  stomach  are  closed 
by  sutures,  and  a  loop  of  jejunum  is  united  to  the  lower 
end  of  the  cavity  in  the  stomach.  It  may  be  per- 
formed either  by  the  anterior  or  posterior  method, 
and  in  no  way  differs  from  the  ordinary  operation  of 
gastro-jejunostomy.  This  operation  may  be  per- 
formed with  advantage  in  two  stages  where  the 
patient  is  not  in  a  very  good  condition  and  unable 
to  bear  the  complete  pi^ocedure.  In  such  cases  the 
gastro-jejunostomy  is  first  performed,  the  bowel  being 
united  to  the  lower  border  of  the  cardiac  end  of  the 
stomach.  From  two  to  four  weeks  later,  when  the 
patient   has    gained    more    strength,    the   second    or 


GASTRECTOMY 


135 


136  CANCER   OF   THE    STOMACH 

radical  operation  is  performed^  tlie  disease  being 
comjDletely  and  widely  excised,  and  botli  cut  ends 
being  closed  by  sutures. 

The  following  case  serves  as  an  illustration  of  the 
method  performed  in  two  stages,  a  procedure  only  to 
be  recommended  when  the  patient  is  too  feeble  to 
bear  the  complete  operation.  The  patient,  a  man 
aged  sixty-three  years,  had  suffered  from  stomach 
symptoms  for  a  year,  a  tumour  having  been  noticed 
for  a  month.  Gastro-enterostomy  was  performed  on 
November  15th,  1900.  A  central  ring  of  cancer  Avas 
found  dividing  the  stomach  into  two  cavities.  The 
patient  was  too  ill  to  bear  gastrectomy.  A  good  re- 
covery was  made,  with  a  rapid  gain  in  weight  and 
strength,  so  that  on  December  20th  the  complete  re- 
moval of  the  growth  by  gastrectomy  was  well  borne. 
The  patient  lived  for  sixteen  months  and  enjoyed  life. 
He  took  his  food  well  up  to  within  a  short  time  of  the 
end. 

Much  has  been  written  as  to  which  is  the  best 
method  of  uniting  the  small  intestine  to  the  remains 
of  the  stomach  in  partial  gastrectomy.  My  own 
feeling  is  that  each  case  must  be  a  law  unto  itself,  for 
I  have  tried  all  the  three  methods — end-to-end,  end- 
to-side,  and  side-to-side — and  I  believe  that  each  can 
be  done  with  equally  good  results  in  suitable  cases. 
I  feel  sure  that  the  end-to-end  method  can  be  more 
safely  accomplished  by  suture  over  the  decalcified 
bone  bobbin  than  by  suture  alone,  but  I  think  that 


GASTRECTOMY  137 

as  a  rule  tlie  end-to-side  method  known  as  Koclier^s 
operation  will  be  found  tlie  most  generally  useful, 
and  in  Professor  Koclier^s  hands,  as  well  as  in  the 
hands  of  other  surgeons,  the  union  of  the  divided 
end  of  the  duodenum  to  a  new  opening  in  the  pos- 
terior or  anterior  wall  of  the  stomach,  when  a  sufficient 
amount  of  duodenum  is  available,  will  be  found  to  be 
the  best  of  all  procedures. 

In  making  this  statement  it  has,  however,  to  be 
borne  in  mind  that  in  case  of  recurrence  the  places 
of  section  of  the  viscera  will  be  the  most  likely  sites 
of  return  growth,  which  would  in  that  case  lead  to 
stenosis,  whereas  if  the  side-to-side  method  were 
adopted  the  recurrence  of  disease  would  be  less 
likely  to  interfere  with  the  passage  of  food 
onwards. 

Moreover,  the  side-to-side  method  is  available  even 
if  a  considerable  portion  of  the  duodenum  should 
have  to  be  removed,  and  it  is  the  method  to  recom- 
mend when  a  patient  is  very  feeble  and  it  is  doubtful 
if  he  will  bear  the  complete  operation  at  one  sitting. 

Partial  gastrectomy  of  the  body  of  the  stomach  as  in 
hour-glass  deformity. — This  operation  is  practically  the 
same  as  the  partial  gastrectomy  of  the  pyloric  endof  the 
stomach,  except  that  the  clamps  are  placed  on  each  side 
of  the  growth,  and  the  section  of  the  stomach  is  made  at 
a  distance  of  not  less  than  1  in.  away  from  the  tumour 
on  each  side.  Neither  the  pyloric  nor  cardiac  orifices 
are  interfered  with,  and  the  junction  is  made  by  a  con- 


138 


CANCER  OF   THE   STOMACH 


GASTRECTOMY  139 

tiniious  serous  suture  of  Pagensteclier's  thread  sur- 
rounding- a  continuous  catgut  suture  embracing  all  the 
coats^  and  bringing  together  the  mucous  surfaces. 


Fig.  11. — Gastrectomy  for  liour-giass  constriction  cUie  to  cancer. 

The  vessels  along  the  lesser  and  greater  curvatures 
are  caught  in  pressure  forceps  or  are  divided  between 
two  ligatures  before  applying  the  clamps. 

Complete  gastrectomy. — This  formidable  operation 
was  first  conceived  and  performed  by  Connor  of 
Cincinnati  in  1883.      Unfortunately  the  j^atient  died 


140  CANCER   OF   THE    STOMACH 

on  the  table,  and  it  was  not  until  fourteen  years 
later  that  the  first  successful  complete  gastrectomy 
was  performed  by  Schlatter,  of  Zurich,  on  September 
6th,  1897,  and  the  second  by  C.  B.  Brigham,  of 
Boston,  on  February  24th,  1898.  In  Schlatter's 
operation  the  cut  end  of  the  oesophagus  was  united  to  a 
loop  of  jejunum,  the  duodenal  opening  being  closed. 
In  Brigham^s  operation  the  cut  ends  of  the  oesophagus 
and  duodenum  Avere  united  over  a  Murphy  button. 

Up  to  October,  1905,  twenty-seven  of  these  opera- 
tions had  been  performed  by  various  operators,  and 
it  is  interesting  to  note  that  Mr.  H.  J.  Paterson  was 
able  to  obtain  information  that  ten  of  the  patients 
were  living  and  well  8  years,  7  years,  5  years,  4}  years, 
4  years,  3^  years,  2  years,  IJ  years,  and  two  others 
at  lesser  periods  after  operation ;  while  others  sur- 
vived 3|  years.  If  years,  13  months,  9  months,  and 
7  months  respectively,  death  from  operation  having 
occurred  in  10  cases — a  remarkable  series  when  the 
severity  and  extent  of  the  operations  are  taken  into 
consideration.  The  operation  is  merely  an  extension 
of  that  already  described  under  partial  gastrectomy, 
the  clamp  seizing  the  oesophagus  just  above  the 
stomach  instead  of  the  stomach  itself.  If  the  stomach 
be  pulled  gently  downwards  the  orifice  may  be  made 
to  protrude  through  the  aperture  in  the  diaphragm 
for  a  little  distance  so  as  to  leave  room  for  the  appli- 
cation of  a  clamp  to  the  lower  end  of  the  oesophagus. 

Although,  if  a  small  portion  of  the  dome  of  the 


GASTRECTOMY  141 

stomacli  be  left  (sub-total  gastrectomy),  as  was  the 
case  in  one  of  my  patients  who  is  still  living  and  well 
over  six  years  later,  the  operation  cannot  then  be 
called  a  complete  gastrectomy,  yet  I  have  no  hesita- 
tion in  advising  this  modification  in  suitable  cases,  as 
it  enables  the  junction  between  the  intestine  and 
oesophagus  to  be  made  so  much  more  easily.  If, 
however,  the  operation  of  total  gastrectomy  is  per- 
formed, the  open  end  of  the  oesophagus  can  be  joined 
to  the  intestine  by  means  of  sutures,  as  in  Schlatter's 
case  ;  by  the  Murphy  button,  as  in  Brigham's  case ; 
or  by  means  of  the  decalcified  bone  bobbin,  as  in  the 
case  to  which  I  have  referred,  all  of  these  patients 
having  recovered. 

Should  it  be  found  that  an  anastomosis  between 
the  oesophagus  and  the  intestine  cannot  be  effected, 
the  opening  into  the  oesophagus  may  be  tightly 
clamped  and  ligatured  in  the  groove  made  by  the 
clamp,  the  mucous  membrane  beyond  the  ligature 
being  taken  away.  The  open  end  of  the  duodenum 
may  then  be  closed  and  a  jejunostomy  performed  by 
the  method  I  have  described  on  p.  152.  This  would 
be  simpler  and  probably  safer  than  performing  a 
duodenostomy  as  has  been  done  in  one  recorded 
case. 

The  passage  of  a  rubber  oesophageal  tube  from 
the  mouth  to  the  stomach  affords  a  help  while  the 
sutures  are  being  applied,  and  somewhat  simplifies 
the    operation,  but  if    a    decalcified   bone  bobbin   is 


142 


CANCER   OF   THE    STOMACH 


being  used  tlie  aid  of  an  (^esophageal  bougie  is  not 
called  for. 

In  some  of  tlie  published  articles  on  gastrectomy 
arbitrary  lines  of  incision  of  the  stomach-wall  have 
been  given  ;  it  seems  to  me  that  this  is  undesirable  ; 
the  extent  of  the  disease  should  be  the  chief  guide 
and  in  no  case  shoukl  the  cardiac  end  of  the  stomach 
be  divided  nearer  to  the  growth  than  from  1  to  2  in. 

As  the  chief  course  of  the  lymphatics  is  along  the 


Fig.  12. 


lesser  curvature  as  far  as  the  point  where  the  gastric 
artery  joins  it,  in  any  case  of  cancer  of  the  pjdoric 
end  of  the  stomach  the  incision  through  the  lesser 
curvature  ought  not  to  be  nearer  the  pylorus  than 
1  in.  from  the  cardiac  orifice.  With  due  precau- 
tion little  or  no  blood  is  lost,  and  all  soiling  of 
the  abdomen  by  stomach  contents  is  avoided  ; 
drainage  is,  therefore,  usually  unnecessary  and 
undesirable. 

The  clamps  I  use  I  have  employed  for  many  years 
for  all  kinds  of  stomach  and  intestinal  surgery  ; 
thev    are    thin    in    the    blade    so    as    not    to    exert 


GASTRECTOMY  143 

unnecessary  pressure,  and  I  usually  have  them 
sheathed  with  indiarubber  tubing  so  that  no 
damage  to  the  visceral  walls  occurs.  They  are 
made  foi"  me  by  Messrs.  Down  Bros.,  and  are  shown 
in  the  diagram. 

The  curved  intestinal  needles  I  use  for  all 
visceral  suturing  I  have  also  employed  since  1884, 
and  with  slight  modification  in  size  and  thickness 
they  have  done  me  very  good  service.  I  never 
use  a  needle-holder. 

The  results  of  gastrectomy  immediate  and  remote. — 
No  useful  purpose  can  be  served  by  comparing  the 
results  of  gastrectomy  Avith  those  of  gastro-entero- 
stomy  for  cancer,  since  the  latter  operation  in 
malignant  disease  is  reserved  for  late  cases  that 
have  passed  the  stage  when  gastrectomy  would  have 
been  a  justifiable  operation  ;  nor  do  I  consider  that 
an  estimate  of  the  true  value  of  gastrectomy  can  be 
attained  by  a  consideration  of  the  earlier  cases 
operated  on  before  the  technique  had  been  perfected. 

Up  to  the  end  of  1905  Koclier  had  performed 
110  partial  resections  of  the  stomach  with  a  mor- 
tality of  24  per  cent.,  but  of  the  cases,  fifty-eight  in 
number,  operated  on  since  1898,  the  mortality  was 
only  15  per  cent.,  a  percentage  closely  corresponding 
to  that  of  the  brothers  Mayo,  who  up  to  the  end  of 
last  year  had  performed  100  gastrectomies  with  a 
mortality  of  14  per  cent. 

In  my  own   practice   since   1896,  the  mortality  for 


144  CANCER   OF   THE    STOMACH 

partial  gastrectomy  lias  been  14  per  cent._,  and  Maydl's 
statistics  give  a  16  per  cent,  mortality. 

We  may  thus  conclude  that  the  immediate  risks  of 
partial  gastrectomy^  as  calculated  from  a  considerable 
series  of  cases,  are  between  14  and  16  per  cent. 

Of  the  twenty-seven  cases  of  total  gastrectomy 
collected  from  all  sources  by  Mr.  H.  J.  Paterson 
(1),  ten  died,  a  mortality  of  36  per  cent. 

Of  the  twenty  cases  of  sub-total  gastrectomy,  sis 
died,  a  mortality  of  30  per  cent. 

The  remote  results  are  equally  interesting  and  not 
less  important,  not  only  from  the  point  of  freedom 
from  recurrence,  but  also  as  to  the  effect  on  the 
general  health  and  comfort  of  the  patient  after  the 
removal  of  the  whole  or  part  of  the  stomach.  I  have 
had  under  my  notice  for  over  six  years  a  case  of  sub- 
total gastrectomy,  and  from  observations  on  this  case 
it  would  seem  as  if  the  whole  of  the  functions  of  the 
stomach  could  be  replaced. 

It  would  at  first  sight  appear  that  as  a  reservoir 
the  stomach  could  not  be  replaced,  but  the  fact  that 
a  meal  of  moderate  size  can  be  taken  shows  that  the 
upper  end  of  the  duodenum,  or  the  lower  end  of 
the  oesophagus,  or  both,  become  dilated  and  serve 
that  purpose,  though,  perhaps,  to  a  limited  extent.  The 
mechanical  functions  of  the  stomach  can  be  vicariously 
performed  by  the  mouth  and  by  a  careful  selection  of 
diet.  The  digestive  functions  of  the  stomach  can  be 
taken  up  by  the  pancreatic  and  the  intestinal   secre- 


CIASTKECTOMY  145 

tionSj  and  tlio  absorption  which  normally  occurs  in 
the  stomach  can  as  easily  take  place  in  the  intestine. 

Pachon  and  Carvalho  (2)  have  shown  that  dogs 
may  gain  in  weight  and  remain  in  perfect  health 
after  removal  of  the  entire  stomachy  and  further 
observations  on  patients  after  complete  gastrectomy, 
as  in  Schlatter's  case,  show  that  perfect  health  is 
compatible  with  absence  of  the  stomach. 

Of  the  twenty-seven  total  gastrectomies  (1),  it  is 
interesting  to  note  that  ten  are  living  and  well  8,  7, 
D,  4|,  4,  o}f,  2,  and  If  years,  and  two  others  at  less 
periods  after  operation,  while  others  survived  3|- 
years,  1|  years,  13  months,  9  months,  and  7  months 
respectively. 

With  regard  to  the  sub-total  gastrectomies,  of  the 
fourteen  patients  who  recovered  from  operation  one 
was  well  74  years,  one  6|  years,  and  one  5^  years 
after  operation,  while  of  the  others,  one  survived 
operation  for  11  years  and  died  of  heart  trouble 
without  recurrence,  one  5  years,  two  2|  years,  two  If 
years,  and  one  1^  years  respectively. 

The  immediate  results  of  partial  gastrectomy  have 
been  mentioned  above,  and  the  final  history  has  been 
obtained  by  Mr.  H.  J.  Paterson  in  fifty-five  of  those 
that  recovered.  Of  the  fifty-five  patients,  thirty-five 
have  died  since  the  operation,  one  died  from  recurrence 
7  years  and  two  5  years  later  ;  but  it  is  interesting  to 
note  that  all  the  other  patients  in  whom  recurrence 
ensued   died  within   3^    years,    so    that   if   a   patient 

10 


146  CANCER    OF   THE    STOMACH 

remains  free  from  recurrence  for  four  or  more  years 
there  would  seem  to  be  a  strong  probability  of  cure. 
Eight  of  the  patients  who  diecl^  lived  over  3  years 
after  operation^  and  the  average  duration  of  life  in 
cases  where  recurrence  took  place  was  just  over  2 
years.  Of  the  patients  Avho  are  apparently  cured^ 
one  is  alive  and  well  14  years_,  one  7^  years^  two  6 
years^  one  5  years,  two  4  years,  five  over  3  years,  and 
three  over  2  years  subsequent  to  operation,  and  one 
was  living  4|  years  after  operation,  but  recurrence 
was  feared.  Thus  nearly  14  per  cent,  of  the  patients 
who  recovered  from  operation  would  seem  to  be  cured 
or  to  have  a  reasonable  prospect  of  remaining  free 
from  recurrence. 

After  a  careful  analysis  of  all  the  cases  operated 
on  I  cannot  help  feeling  that  far  too  gloomy  a  view 
is  taken  of  cancer  of  the  stomach,  for  if  the  disease 
be  caught  early  and  a  wide  excision  peformed,  care 
being  taken  to  remove  the  lymphatic  area  of  the 
stomach  Avitli  the  glands  along  the  lesser  curvature, 
results  even  better  than  those  I  have  just  mentioned 
will  be  obtained.  Our  great  hope  of  success,  I  venture 
to  state  at  the  risk  of  being  accused  of  reiteration, 
lies  in  earl 3^  and  complete  removal. 


CHAPTER    X 

mDICATIONS  FOR  THE  PERFORMANCE  OF 
GASTRO-ENTEROSTOMY  IN  MALIGNANT 
DISEASE    OF    THE    STOMACH 

(a)  In  dilatation  of  the  stomach  due  to  stenosis  of 
the  p^dorus  from  cancer^  where  the  disease  is  too 
diffused  or  the  glands  are  too  much  involved  for 
successful  gastrectomy. 

(h)  The  operation  of  gastro-jejunostomy  is  not  to 
be  recommended  in  cases  of  cancer  or  sarcoma  of  the 
stomach  where  the  disease  is  limited  in  extent  and 
capable  of  radical  removal  by  gastrectomy. 

(c)  In  case  of  cancer  invading  the  pylorus  or  py- 
loric end  of  the  stomach  or  the  duodenum  incapable  of 
radical  removal,  even  though  obstruction  of  the  lumen 
be  at  the  time  incomplete^  a  gastro-jejunostomy  should 
be  performed  in  order  to  prevent  obstruction. 

{d)  Under  similar  conditions  the  short-circuiting 
operation  may  cause  a  great  diminution  in  the  size  of 
the  growth  and  in  its  activity,  by  putting  it  at  rest. 

(e)  In  hour-glass  stomach  due  to  cancer,  where 
the  growth  is  tending  to   produce   a  constriction  in 


148  CANCER   OF   THE   STOMACH 

some  part  of  tlie  stomach  and  so  leading  to  obstruc- 
tion, a  sliort-circuiting  operation,  Avliereby  the  proxi* 
mal  gastric  cavity  is  connected  to  the  jejunum,  is 
capable  of  affording  great  relief  and  of  retarding 
the  growth  of  the  tumour. 

(/)  Hi  doubtful  tumours  at  the  pylorus,  which  are 
adherent  to  the  liver,  pancreas,  and  adjoining  parts, 
and  where  the  glands  are  involved,  the  performance 
of  a  gastro-jejunostomy  may  prove  entirely  curative, 
as  chronic  ulcer  with  thickening  may  simulate  cancer, 
and  in  that  case  will  be  cured  by  the  rest  secured  by 
the  operation. 

{g)  In  ha3morrhage  from  cancer  or  sarcoma  of  the 
stomach  and  when  the  growth  cannot  be  removed,  a 
gastro-enterostomy  may  give  great  relief,  and  secure 
arrest  of  the  bleeding. 

(//)  In  persistent  vomiting,  either  from  retention 
or  from  irritation,  a  gastro-jejunostomy  may,  if  the 
disease  is  not  too  far  advanced,  give  great  relief. 

(t)  In  dilatation  of  the  stomach  dependent  on  pres- 
sure on  the  pylorus  or  duodenum  from  tumour  of  the 
pancreas,  liver,  or  gall-bladder  incapable  of  removal, 
a  short-circuiting  operation  may  be  the  means  of 
giving  great,  though  perhaps  only  temporary,  relief. 

(/)  In  certain  cases  where  a  cancer  of  the  pyloric 
end  of  the  stomach  is  removable  and  the  glands  are 
not  too  involved  for  a  radical  operation  to  be  under- 
taken, but  in  which  the  patient  is  too  feeble  to  bear 
the   major    operation,  a   gastro-jejunostomy    may  be 


GASTRO-ENTEEOSTOMY  149 

performed,  and  after  the  patient  lias  improved  in 
the  course  of  two  or  three  weeks  the  gastrectomy 
may  be  carried  out  with  great  expedition,  as  the 
anastomosis  has  already  been  done  and  will  save  a 
considerable  amount  of  time. 

It  is  not  necessary  to  mention  the  many  indications 
for  operation  w^lien  the  disease  is  simple,  but  I  would 
remark  that  in  all  cases  of  chronic  ulcer,  whether 
producing  obstruction  or  not,  a  gastro-jejunostomy 
should  be  done  as  a  curative  operation  for  the  ulcer 
and  a  preventative  of  cancer,  to  which  chronic  ulcer 
strongly  predisposes. 

The  operation  of  gastro-enterostomy. — The  operation 
of  gastro-enterostomy  was  first  performed  by  Wolfler 
at  the  suggestion  of  Nicoladini  on  September  28th, 
1881.  The  patient,  who  was  suffering  from  cancer 
of  the  pylorus,  lived  for  four  months. 

For  some  years  later  so  little  confidence  was  placed 
in  this  and  other  operations  on  the  stomach,  that  cases 
were,  as  a  rule,  treated  medically  until  almost 
moribund  before  surgical  treatment  was  considered 
advisable,  with  the  result  that  the  mortality  was 
appalling.  For  instance,  between  1881  and  1885  the 
mortality  of  gastro-enterostomy  was  65'7  per  cent. 
There  is,  however,  a  very  different  statement  to  make 
to-day,  when  one  can  point  to  a  personal  experience  of 
a  series  of  nearly  300  posterior  gastro-jejunostomies, 
undertaken  for  both  simple  and  malignant  disease, 
with  a  mortality  of  only  3-4  per  cent,  and  to  a  series 


150  CANCER   OF   THE    STOMACH 

of  nearly  200  cases  in  which  the  operation  was  per- 
formed in  my  private  practice  for  ulcer  and  its 
complications^  with  a  mortality  of  only  To  per  cent. 

These  and  similar  results  by  other  surgeons  bring 
the  procedure  well  within  the  realm  of  safety,  and 
seeing  that  it  has  to  be  undertaken  in  many  cases 
for  diseases  that  would  be  otherwise  inevitably  fatal, 
it  may  be  looked  on  as  an  operation  the  benefits  of 
which  not  even  the  most  conservative  practitioner 
can  afford  to  ignore.  These  changes  have  been 
brought  about,  not  only  by  patients  being  operated 
on  at  an  earlier  stage  and  under  more  favourable 
conditions — for  many  of  my  patients  have  been  ex- 
tremely ill  at  the  time  of  operation — but  also  by 
greater  care  in  technical  details,  by  greater  expedi- 
tion in  operating,  by  more  careful  asepsis,  by  the 
avoidance  of,  or  greater  care  in,  the  use  of  irritating 
antiseptics,  by  the  prevention  or  better  treatment  of 
shock,  by  care  in  post-operative  treatment,  such  as 
early  feeding  subsequently  to  operation,  and  by  the 
careful  preparation  of  the  patient. 

The  preparation  of  the  i^atient. — It  has  been  the 
custom  with  many  surgeons  to  put  patients  suifering 
from  disease  of  the  stomach  through  a  long  course  of 
preliminary  treatment,  such  as  frequent  lavage  of  the 
stomach  and  abstention  from  food  before  operation. 
This,  as  a  rule,  is  quite  unnecessary,  and  certainly 
inadvisable  in  the  greater  number  of  cases ;  first, 
because  the  treatment  is  depressing  and  debilitating 


GASTHO-ENTEROSTOMY  1 5 1 

in  the  case  of  patients  already  exhausted  by  a  long- 
illness  ;  secondly,  as  proved  by  Dr.  Harvey  Cushing^s 
bacteriological  investigations,  the  stomach  contents 
speedily  become  aseptic  if  the  mouth  be  cleansed  and 
aseptic  foods  administered  ;  and  thirdly,  as  proved  by 
ample  clinical  experience,  elaborate  preliminary  treat- 
ment is  unnecessary  to  success. 

If  the  stomach  is  greatly  dilated  and  the  contents 
are  foul,  then  lavage  with  simple  boiled  water  night 
and  morning  is  adopted  on  the  day  before  operation. 
The  careful  cleansing  of  the  mouth  and  teeth  and 
the  administration  of  foods  sterilised  by  boiling  are 
advisable.  The  last  light  meal  is  given  the  night 
before,  about  twelve  hours,  and  a  nutrient  enema  is 
given  about  one  hour  before  operation.  In  ordinary 
cases  no  lavage  is  adopted,  but  care  is  exercised  in 
cleansing  the  mouth  and  giving  sterilised  food  for 
thirty-six  or  forty-eight  hours  prior  to  operation,  and 
a  nutrient  enema  consisting-  of  1  oz.  of  brandy, 
1  oz.  of  liquid  peptonoids,  and  10  oz.  of  normal 
saline  solution  is  administered  about  an  hour  before 
operation. 

Every  patient  is  enveloped  in  a  suit  of  cotton  wool 
made  by  the  nurse  out  of  gamgee  tissue,  and  each 
has  an  injection  of  from  5  to  10  ]){  of  liquor  strycli- 
nia3  (B.P.)  administered  subcutaneously  before  or 
during  the  operation.  The  preparation  of  the  skin 
and  other  aseptic  details  of  the  operation  differ  in  no 
respect  from  those  observed  in  operations  generally. 


152  CAXCER    OF   THE    STOMACH 

Althougli  tlie  operation  of  gastro-enterostoni}^  lias 
been  performed  in  many  different  ways  there  are 
practically  only  two  distinct  methods  :  one  Wolfler\s, 
in  which  the  jejunnm  is  fixed  to  the  anterior 
stomach-wall,  and  the  other  von  Hacker^s,  in  which 
the  anastomosis  is  effected  between  the  jejunum  and 
the  posterior  Avail  of  the  stomach.  From  a  some- 
what extensive  experience  of  the  two,  I  have  no 
hesitation  in  strongly  recommending  the  posterior, 
where  that  operation  is  possible,  for  it  must  be 
granted  that  there  are  some  exceptional  cases  in 
which,  on  account  of  adhesions  to  the  pancreas, 
extensive  involvement  of  the  posterior  wall  of  the 
stomach  by  growth  or  from  congenital  deformity, 
''  a  very  short  meso-colon,"  the  anterior  method  may 
have  to  be  selected  or  a  Roux^s  operation  performed. 

The  following  is  a  description  of  the  operation 
Avhich  I  am  in  the  habit  of  performing  : 

The  abdomen  is  opened  by  an  incision  3  to  4  in. 
long,  1  in.  to  the  right  of  the  middle  line  above  the 
umbilicus.  The  stomach  is  thus  exposed.  Sterilised 
gauze  is  laid  on  the  abdomen  surrounding  the  wound. 
The  great  omentum  and  the  transverse  colon  are  then 
lifted  up  and  brought  out  of  the  wound,  thus  exposing 
the  under  surface  of  the  transverse  meso-colon  and 
the  attached  part  of  the  jejunum  on  the  left  side  of 
the  second  lumbar  vertebra.  The  bowel  is  caught 
up  in  a  clamp  just  beyond  the  duodeno-jejunal  flexure, 
at  which  place  the  anastomosis  is  made,  thus  avoiding 


GASTRO-ENTEROSTOMY  153 

any  loop.  A  vertical  slit  is  tlien  made  in  the  trans- 
verse meso-colon  between  tlie  blood-vessels,  wliich  are 
readily  seen.      By  pressing  witli  the  left  hand  above 

Fig.  13. 


the  colon  the  posterior  Avail  of  the  stomach  is  made 
to  project  through  the  opening  in  the  meso-colon, 
the  lower  border  of  the  stomach  being  readily  recog- 
nised by  the  blood-vessels  which  are  coursing  along 


154 


CANCER   OF   THE    STOMACH 


it.  The  most  dependent  part  of  the  stomach  close 
to  the  lower  border  is  then  brought  through  the  slit 
and  grasped  by  a  clamp  as  shown  in  the  diagram. 

The  great  omentum  and  the  transverse  colon  are 
then  returned  into  the  abdomen  above  the  parts  to  be 
anastomosed,  and  covered  with  a  sterilised  gauze 
pad.  The  two  clamped  portions  of  the  bowel  and 
stomach  are  now  placed  side  by  side  with  a   strip  of 

Fig.  14.. 


gauze  behind  and  between  them.  Two  or  three 
vessels  passing  from  the  main  gastro-epiploic 
arteries  across  the  part  where  the  stomach  has  to 
be  incised  are  ligatured  in  their  continuit}^  so  as 
to  save  bleeding  when  the  stomach  is  cut.  A  con- 
tinuous suture  of  No.  1  Pagenstecher  thread  in 
a  round,  fully-curved  needle  is  employed  to  unite  the 
serous  surfaces  for  a  distance  of  from  2  to  2^  in., 
the  needle  being  then  laid  aside  threaded.  A  quarter 
of  an  inch  in  front  of  this  serous  suture  the  two  viscera 


GASTRO-ENTEEOSTOMY  155 

are  incised^  and  the  edges  arc  united  by  a  chromic 
catgut  suture^  which  takes  up  all  the  coats  and  brings 
into  apposition  the  mucous  membrane  of  the  intestine 
and  stomach.  This  suture  is  continued  round  the 
circle  until  it  reaches  the  point  where  it  began,  when 
the  suture  is  at  once  tied  off  and  cut  short.  The 
serous  suture  previously  laid  aside  is  now  taken  up 
and  continued  round  the  front  half  of  the  circle  in 
front  of  the  newly-made  opening  until  the  point  is 
reached  where  it  began,  when  the  two  ends  are 
knotted  and  cut  short.  The  edges  of  the  aperture 
are  thus  united  firmly  by  a  serous  and  a  marginal 
suture.  The  clamps  are  now  removed  and  the 
piece  of  gauze  behind  the  anastomosed  viscera  is 
then  drawn  out  and  the  omentum  and  stomach  are 
brought  down  to  their  normal  position.  In  order 
that  there  may  be  no  kinking  at  the  point  of 
junction  I  am  accustomed  to  place  one  or  two  addi- 
tional sutures  on  the  distal  side  of  the  united  viscera 
and  to  bring  the  distalpart  of  the  jejunum  over  to 
the  right  side  of  the  spine  in  arranging  the  visceral 
toilet.  Two  or  three  interrupted  sutures  are  used 
to  unite  the  margin  of  the  meso-colic  opening  to 
the  stomach  and  jejunum.  The  omentum  and  trans- 
verse colon  are  then  brought  down  into  their  normal 
position,  and  the  abdomen  is  closed  by  a  continuous 
No.  3  catgut  suture^  Avhich  first  unites  the  peritoneum 
and  the  posterior  rectus  sheath  together,  and  the 
same  suture  returning  unites  the  anterior  sheath  of 


156 


CANCER    OF   THE   STOMACH 


tlie  rectus  :  but  in  order  to  o-ive  additional  streno-th 
to  the  abdominal  wall  I  usually  pass  from  three  to 
six  through-and-through  Xo.  2  slightly  chromicised 
catgut  sutures,  which,  however,  do  not  penetrate  the 


Fig.  15.— (-Ta.stro-jejunostomy  showing  the  relation  of  the 
jejnniim  to  the  stomach  after  the  anastomosis  has  been 

effected. 

skin,  and  which  are  cut  short  and  buried  beneath 
it.  The  van  Horn  20-day  chromic  sutures  are  here 
very  useful.  The  skin  is  then  brought  together 
either  l)y  means  of  several  interrupted  silkworm-gut 


GABTKO-ENTEEOSTOMY  157 

sutures  or  by  tlie  well-known  Micliers  metal  clips, 
which  I  myself  prefer. 

It  will  be  noticed  that  I  have  said  nothing  of  making 
the  opening  in  the  stomach  oblique_,  nor  of  excising  re- 
dundant mucous  membrane,  nor  of  displacing  the  large 
vessels  coursing  along  the  greater  curvature,  for  these 
modifications  of  the  operation  are  quite  unnecessary. 

The  anastomotic  opening  should  be  made  close  to 
the  lower  border  of  the  stomach,  and  the  opening 
should  never  be  less  than  2  in.  in  length.  If,  as 
should  be  the  case,  the  mucous  margins  of  the 
stomach  and  bowel  are  united,  there  is  no  fear  of 
serious  subsequent  diminution  of  the  opening  by 
cicatricial   contraction. 

The  modification  I  used  to  adopt  of  inserting 
a  decalcified  bone  bobbin  before  completing  the 
anterior  half  circle  of  the  continuous  sutures  secures 
an  immediately  patent  opening  and  removes  the 
possibility  of  kinking.  Those  who  have  had  the 
opportunity  of  observing  my  cases  after  the  employ- 
ment of  the  bone  bobbin  and  cases  in  which  the 
simple  suture  has  been  used  without  any  splint,  have 
expressed  to  me  their  belief  that  the  recovery  is 
smoother  than  when  the  bobbin  is  not  used  ;  but  as 
a  matter  of  fact  I  have  employed  simple  sutures 
for  a  considerable  time,  and  have  found  the  results 
equally   satisfactory. 

The  use  of  the  Murphy  button  is  on  quite  a 
different   principle,    as    it    acts    by    causing   pressure 


158  CANCER    OF   THE    STOMACH 

necrosis  of  the  apposed  surfaces.  It  can  certainly 
be  done  a  little  quicker,  though  really  very  little 
time  is  saved ;  but  the  two  fatal  objections  to  its 
use  are  the  small  size  of  the  oi^ening,  Avhich  tends 
to  contract,  and  the  danger  of  the  button  falling 
back  into  and  being  retained  in  the  stomach,  a 
danger  which  is  proved  to  have  frequently  occurred 
in  practice,  necessitating  in  many  cases  a  further 
operation.  I  therefore  personally  never  employ  it, 
and  cannot  recommend  its  use  to  others. 

A  modification  of  the  posterior  operation  has  been 
suggested  by  Dr.  W.  J.  Mayo  (1)  which  has  given 
him  satisfactory  results.  The  operation  which  is 
shown  in  the  diagrams  consists  in  attaching  the 
jejunum  to  the  stomach  in  its  vertical  direction,  the 
advantao'e  claimed  beino-  that  it  does  not  alter  the 
axis  of  the  jejunum. 

The  suggestion  of  McGraw  to  make  the  incision 
safer  by  the  employment  of  an  elastic  ligature  is  to 
my  mind  neither  necessary  from  the  point  of  view  of 
safety  nor  desirable  from  that  of  accuracy ;  more- 
over, as  the  anastomosis  has  to  be  made  by  a  process 
of  sloughing  which  takes  some  days  to  complete,  and 
always  leads  to  an  opening  of  uncertain  size  and  one 
with  a  tendency  to  contract,  I  have  the  feeling  that 
the  method,  though  ingenious,  is  clumsy  and  inexact, 
and  one  which  should  not  be  employed  by  a  surgeon 
who  is  capable  of  adopting  the  more  exact  technique 
herein  described. 


PLATE    XI. 


Completed  operation  from  behind  mar^^in  of  torn  mesocolon  attached 
by  several  interrujDted  sntiires  to  line  of  nnion. 

(W.  J.  Mayo.) 


To  face  p.  158. 


Ailhtrd  4  Son,  Impr. 


PLATE    XII. 


^1 


v^to^'"" 


Forceps  in  place  and  anastomosis  half  completed  by  sntiire. 

(TF.  J.  Mayo.) 


To  face  ji.  158. 


Adlard  S-  Son,  Tmjn; 


PLATE    XIII. 


mi 


I 


\: 


1 


A'SS"^%>4E* 


Completed  operation  from  behind  margin  of  torn  mesocolon  attached 
by  several  interrupted  sutui"es  to  line  of  union. 

(W.  J.  Mayo.J 


Tofacf  p.   158. 


Adlard  ij-  Son,  lm]»\ 


PLATE    XIV. 


Completed  operation  from  in  front.  Anastomotic  opening  shows 
through  as  darkened  area  on  posterior  wall.  Note  that  it  goes  to 
the  bottom  of  the  gastric  cavity  and  slightly  anterior,  as  indicated 
by  suture  line  in  the  omental  attachment. 

fW.  J.  Mayo.) 


To  fac 


log: 


Adlurd  ^'  Son,  Impr. 


GASTRO-ENTEROSTOM  Y  1 59 

When  an  operation  involving  so  many  possibilities 
of  danger^  and  often  undertaken  in  very  serious  con- 
ditions, can  be  accomplished  with  a  little  over  1  per 
cent,  mortality  in  over  100  consecutive  cases  of  ulcer 
and  other  simple  disease  of  the  stomach,  there  cannot 
be  much  seriously  wrong  with  the  technique,  and 
when  I  see  alternative  methods  suggested,  such  as 
E/Oux^s  Y  operation,  or  that  of  short-circuiting  the 
jejunal  loop,  both  of  which  involve  the  making  of  a 
double  anastomosis,  and  which  are  acknowledged  to 
be  done  in  order  to  avoid  the  complication  of  the 
vicious  circle — a  complication  which  does  not  occur 
when  the  operation  I  have  described  in  detail  is 
performed — I  am  at  a  loss  to  understand  why  such 
operations  continue  to  be  done  save  under  very  ex- 
ceptional circumstances. 

Although  I  have  given  a  description  of  gastro- 
enterostomy as  I  have  done  it  for  several  years,  and 
one  which  I  know  has  stood  the  test  of  numbers  and 
of  time,  I  feel  that  for  a  text-book  the  description  of 
the  operation  would  not  be  complete  were  I  not  to 
describe  other  methods. 

Anterior  gastro  -  enterostomy. —  Anterior  gastroen- 
terostomy is  performed  like  the  posterior,  except 
that  in  this  case  the  anastomosis  of  the  jejunum  with 
the  stomach  is  made  at  the  lower  border  of  the  an- 
terior surface,  and  instead  of  the  attachment  being 
made  close  to  the  commencement  of  the  jejunum  it 
has   to   be   effected   at   least  12   to    15   in.  from   the 


160 


CANCER   OF   THE    STOMACH 


flexure,  since  the  jejunal  loop  lias  to  pass  over  the 
transverse  colon  in  order  to  reach  the  point  of  attach- 
ment to  the  stomach. 


ih^  -  - 


(a>--)re^ 


Fig.  16. — Anterior  gastro-jejunostomy  showing-  tlie  correct 
position  (a)  and  the  incorrect  position  (?>)  for  the 
anastomosis. 


Otherwise,  in  the  use  of  the  clamps  in  the  methods 
of  attachment,  whether  by  suture,  by  decalcified  bone 


gastro-e:n^terostomy  igi 

bobbin^  by  metal    button,  or   by   elastic   ligature,  it 
differs  in  no  respect  from  the  posterior  operation. 

The  disadvantage,  as  we  shall  see  later,  is  in  the 
long  loop  of  jejunum,  which  is  apt  to  give  rise  to 
several  complications.  Personally,  I  always  perform 
the  posterior  operation,  except — 

(1)  When  the  meso-colon  is  very  short,  giving  no 
room  through  which  to  make  the  anastomosis; 

(2)  When  extensive  and  firm  adhesions  of  the 
posterior  wall  of  the  stomach  prevent  a  portion  being 
drawn  through  a  slit  in  the  meso-colon  ;  and 

(3)  When  cancer  invades  the  posterior  wall  so 
extensively  as  to  leave  no  part  of  it  safely  available 
for  operating  on. 

Entero-anastomosis  of  the  jejunal  loop. — This  opera- 
tion has  been  suggested  as  a  means  of  preventing  the 
vicious  circle  or  of  arresting  it  should  it  unfortunately 
have  occurred. 

In  posterior  gastro-enterostomy  without  a  loop,  or 
with  a  very  short  interval  between  the  duodeno- 
jejunal flexure  and  the  anastomosis,  an  entero- 
anastomosis  is  neither  necessary  nor  desirable,  as  the 
vicious  circle  does  not  happen  if  the  operation  has 
been  properly  performed. 

After  the  anterior  operation  with  the  necessarily 
long  jejunal  loop,  stagnation  of  fluids  may  occur  in 
it  giving  rise  to  regurgitant  vomiting  or  to  inflam- 
mation or  ulceration  of  this  part  of  the  jejunum. 

Some  surgeons  who  regularl}^  perform  the  anterior 

11 


162 


CANCER   OF   THE    STOMACH 


operation    adopt   en tero- anastomosis   as    part   of    the 
technique,  employing  it  as  a  preventive  method. 
Fig.  17. 


I  have  only  had  to  perform  the  operation  on  three 
occasions,    and  on    each   after  anterior   gastro-ente- 


GASTRO-ENTEROSTOMY  163 

rostomy,  twice  after  my  very  early  operations  in 
wliicli  a  long  loop  was  employed,  giving  rise  to 
regurgitant  vomiting,  which  entero-anastomosis  cured, 
and  once,  a  year  after  operation  by  another  surgeon, 
in  which  great  pain  and  distress  were  caused  by  acute 
inflammation  and  ulceration  of  the  whole  of  the  long 
jejunal  loop ;  in  this  case  the  condition  was  also 
relieved  by  the  anastomosis.  The  operation  is  per- 
formed as  follows  :  The  lowest  part  of  the  ascending 
limb  of  the  loop  (a)  is  grasped  by  a  rubber-covered 
clamp  and  approximated  to  a  part  (b)  on  the  des- 
cending coil  of  jejunum  beyond  the  gastro-jejunal 
opening,  which  is  also  clamped,  and  an  opening  of 
from  1  to  2  in.  is  made  between  one  and  the  other 
in  exactly  the  same  way  as  already  described  for 
making  the  opening  between  the  stomach  and 
jejunum. 

Roux's  operation; — This  method,  which  is  also 
spoken  of  as  the  Y  operation,  was  suggested  and 
carried  out  by  Roux,  and  is,  I  believe,  still  performed 
by  him  and  by  some  other  operators  as  a  routine 
procedure. 

At  the  International  Surmcal  Con  ogress  held  at 
Brussels,  1905,  Von  Eiselberg  (2)  stated  that  he 
always  employed  Roux\s  operation  as  a  routine 
procedure. 

This  operation  was  invented  when  regurgitant 
vomiting  or  the  vicious  circle  was  a  frequent  com- 
plication   of   gastro-enterostomy,  and    then  it  was  a 


164 


CANCEE    OF   THE   STOMACH 


distinctly    useful    modificatiou^  as  it  is  still  when   a 
posterior  gastro-enterostomy  cannot  be  performed  on 


Fig.  is. — Eonx's  operation. 

account   of    extensive   adhesions   or   from    extent   of 
ofrowth. 


GASTRO-ENT  EK08T0M  Y 


165 


As  an  ordinary  procedure^  Roux^s  operation  is  not 
necessary^  and  I  think  it  undesirable^  as  it  involves 
a  double  anastomosis. 


(S^ 


:<^ 


N^ 


vt# 


Fig.  19. — Eoux's  operation. 

It  may  be  performed  as  follows  :  After  clamping 
the  portion  of  stomach  to  which  the  anastomosis  is  to 
be  made,  a   loop  of    jejunum  of   about  9   in.,  about 


166  CANCER   OF   THE    STOMxVCH 

10  in.  from  tlie  duodeno-jejunal  flexure,  is  grasped  by 
a  pair  of  long  rubber-covered  clamps. 

This  loop  is  divided  at  A ;  the  023en  end  of  the 
bowel  E  is  then  sutured  to  a  lateral  opening  made 
into  the  other  arm  of  the  loop  at  b.  The  open  end  c 
is  then  stitched  to  an  opening  made  into  the  stomach 
at  D. 

When  completed,  the  operation  presents  the  ap- 
pearance shown  in  the  diagram. 

I  have  carried  out  the  procedure  with  advantage 
in  extensive  perigastritis  with  matting  of  the  viscera, 
in  wide-spread  gastric  carcinoma,  and  in  jejunal  ulcer 
where  it  was  necessary  to  excise  part  of  the  ulcerated 
jejunal  loop. 

After-treatment. — AVhen  the  patient  is  returned  to 
bed  he  is  propped  up  at  an  angle  of  about  30°  by 
means  of  pillows  placed  under  the  back  and  shoulders. 
As  soon  as  the  effects  of  the  ansesthetic  have  passed 
off  the  elevation  may  be  increased  to  45'^.  A  narrow 
bolster,  covered  with  jaconet  and  a  linen  bolster-case, 
is  placed  under  the  thighs  and  fastened  to  the  upper 
bar  at  the  top  of  the  bed  by  means  of  webbing  straps. 
This  sling  prevents  the  patient  from  slipping  down 
in  bed  and  also  flexes  the  thighs  and  thus  causes  re- 
laxation of  the  abdominal  muscles.  By  maintaining 
the  semi-sitting  posture  it  largely  contributes  to  the 
absence  of  post-operative  vomiting,  and  at  the  same 
time  relieves  the  breathing.  If  preferable  the  pillows 
may  be  taken  out  at  night  aud  the  patient  allowed  to 


GASTRO-ENTEHOSTOMY  1 67 

be  at  a  lower  angle  on  the  right  side,  but  it  is  wise 
to  keep  the  patient  propped  up  during  the  first 
twenty-four  hours. 

The  gamgee  leggings  may  be  taken  off,  but  the 
sleeves  or  jacket  should  be  allowed  to  remain  on  for 
some  days  to  prevent  chilling.  A  warm  nutrient, 
consisting  of  salt  solution  1  pint,  brandy  1  oz.,  liquid 
peptonoids  1  oz.,  is  then  administered.  This  is  re- 
repeated  every  four  hours  during  the  first  forty-eight 
hours  with  a  less  quantity  or  even  without  the  brandy 
if  thought  desirable,  after  which  it  may  be  gradually 
discontinued.  If  the  nutrient  enemata  are  not  re- 
tained simple  saline  nutrients  should  be  tried.  As 
soon  as  the  patient  has  come  round  from  the  anaes- 
thetic, feeding  by  the  mouth  may  be  commenced. 
Water,  or  better  still,  albumen-water,  is  given,  J  oz. 
at  a  time,  every  half  hour.  If  there  is  no  sickness 
or  nausea  the  quantity  is  increased.  Thirst  may  be 
relieved  by  permitting  the  patient  to  wash  out  the 
mouth  frequently  with  water  or  soda-water.  If  there 
is  severe  abdominal  pain,  10  gr.  of  aspirin  should  be 
given  by  the  mouth  and  repeated,  if  necessary,  in 
two  or  three  hours.  Morphine  should  not  be  given, 
as  it  is  apt  to  cause  sickness  and  distension  of  the 
intestines.  The  abdominal  bandage,  which  is  applied 
firmly  after  the  operation,  may  have  to  be  loosened 
to  give  greater  comfort. 

On  the  day  after  the  operation  the  amount  of  food 
given  is  steadily  increased.      It  is  impossible  to  give 


168  CANCER   OF   THE    STOMACH 

a  routine  dietary  for  tliese  cases_,  as  the  tastes  of  tlie 
patients  have  to  be  considered.  The  following  may 
be  taken  as  a  basis  for  the  feeding  during  the  first 
week.  Feeding  during  the  night  should  be  regular^ 
unless  the  patient  is  asleep.  It  is  only  in  exceptional 
cases  that  it  is  necessary  to  disturb  the  patient : 

First  day  :  Water^  albumen- water,  tea,  ^  oz.  to 
1  oz.  every  half  hour. 

Second  day :  Ditto,  with  barley-water  and  plasmon ; 
meat  juice  or  jelly  in  teaspoonful  doses  ;  coffee  con- 
taining a  little  cream  or  milk  ;  whey  with  a  little 
cream  :   2  oz.  feeds. 

Third  day  :  Ditto  ;  broth  with  pounded  chicken, 
Benger's  food,  made  with  milk. 

Fourth  day  :  Custard,  junket,  whe}^,  milk  jelly^ 
tea  or  colfee,  or  any  of  above  fluids  that  j^^tient 
cares  for. 

Fifth  day :  Pounded  chicken,  fish,  steamed  or 
lightly-boiled  eggs  and  bread  crumbs ;  fluids  as 
before. 

Sixth  day  :  Same  as  previous  day,  with  the  addi- 
tion of  milk  pudding  or  brains. 

Seventh  day  :  Same  as  previous  day.  Bread  and 
butter,  toast  and  mashed  potato  and  gravy  may  be 
given  in  small  quantities.  Pounded  or  finely-minced 
chicken  and  mutton  in  broth  or  in  sandwiches  can, 
as  a  rule,  be  allowed. 

During  the  second  week  the  amount  of  solid  and 
liquid  food  is  increased,  with  longer  intervals  between 


GASTRO-ENTEROSTOMY  169 

feeding.  Care  should  be  exercised  in  diet  for  some 
months  :  condiments  should,  as  a  rule,  be  avoided,  and 
highly-seasoned  or  twice-cooked  foods  be  eschewed. 

After  the  operation  the  rectum  is  washed  out  every 
twenty-four  hours  with  a  pint  of  hot  soapy  water. 
Should  there  be  distension  of  the  abdomen  from  flatus, 
a  tablespoonful  of  turpentine  or  10  V{  of  oil  of 
cajuput  is  added  to  the  enema.  No  aperient  is  given 
as  a  routine  measure,  and  as  a  rule  none  is  given  be- 
fore the  fourth  day,  but  if  one  is  required,  that  to 
which  the  patient  has  been  accustomed  is  preferred. 
In  some  cases  calomel,  followed  by  a  saline,  in  others 
cascara,  and  in  others  a  compound  aloin  tablet  may 
be  required. 

The  time  that  a  patient  is  kept  in  bed  varies  with 
the  nature  of  the  case.  Old  people,  especially  cancer 
patients,  may  often  be  allowed  to  sit  up  in  a  chair 
about  the  tenth  day,  though  they  may  be  moved  on 
the  sofa  within  a  week.  In  these  cases  the  abdominal 
wound  must  be  firmly  sewn  up  and  supported  by 
strapping.  The  average  time  for  a  patient  to  stay  in 
bed  after  an  operation  on  the  stomach  is  from  two 
to  three  weeks. 

Complications. — The  complications  that  may  follow 
gastro-enterostomy  are  : 

(1)  Regurgitant  vomiting. 

(2)  Contraction  of  the  new  orifice. 

(3)  Peptic  jejunal  ulcer. 

(4)  Pneumonia  or  other  chest  complications. 


170     CANCER  OF  THE  STOMACH 

(5)  Adhesions. 

(6)  Intestinal  obstruction. 

(7)  ISTon-union  and  separation  of  tlie  anastomosed 
viscera. 

(8)  Hernia  of  tlie  intestine  tlirougli  tlie  loop  in  tlie 
anterior,  or  tlirongli  the  mesenteric  slit  in  the  pos- 
terior operation. 

(9)  Exhaustion. 

(10)  Heemorrhage. 

(11)  Dragging  on  the  jejunum  when  a  dilated 
stomach  retracts  ;  this  may  occur  if  the  ligament  of 
Treiz  is  short  or  displaced  to  the  right  of  the  stomach 
and  there  is  no  jejunal  loop  (3). 

(1)  Regurgitant  vomiting. — Regurgitant  vomiting 
is  a  complication  that  used  frequently  to  follow  the 
operation  of  gastro-enterostomy,  and  when  severe  it 
was  not  infrequently  fatal.  It  is  now  seldom  and 
should  never  be  seen_,  as  it  is  entirely  due  to  faulty 
technique. 

It  is  essentially  due  to  obstruction  to  the  passage 
onwards  of  the  duodenal  contents,  either  from  paresis 
of  the  intestine  that  has  been  handled  too  freely  or 
paralysed  by  the  too  firm  pressure  of  a  faulty  clamp ; 
or  to  kinking  of  the  bowel  at  the  point  of  anastomosis; 
or  to  some  obstruction  by  adhesions  or  pressure  be- 
yond the  gastro-jejunal  opening  ;  or  to  the  presence 
of  a  jejunal  loop  as  in  anterior  gastro-enterostomy. 
It  will  thus  be  seen  that  the  complication  is,  as  a 
rule,  due  to  intestinal  obstruction  or  to  stasis. 


GASTRO-ENTEROSTOMY  171 

The  theories  that  have  been  put  forward  to  account 
for  it  are  : 

(a)  The  presence  of  bile  in  the  stomachy  which 
Dastre's  experiments  on  dogs  absolutely  disproved  (4) . 

(b)  The  presence  of  a  loop  on  the  proximal  side  of 
the  opening  into  the  stomach,  which  is  disproved  by 
the  large  numbers  of  successful  anterior  gastro-en- 
terostomies  that  must  necessarily  have  such  a  loop. 

(c)  By  the  situation  of  the  opening  not  being  at  a 
dependent  part  of  the  stomach,  also  disproved  by 
many  of  the  early  successful  cases  in  which  the 
opening  was  not  made  close  to  the  lower  border  of 
the  stomach. 

{d)  The  presence  of  pancreatic  fluid  in  the  stomach, 
disproved  by  Moynihan\s  case,  in  which  a  ruptured 
intestine  at  the  duodeno-jejunal  flexure  was  treated 
by  closing  both  ends  of  the  rupture  and  performing 
a  gastro-jejunostomy,  so  that  all  the  bile  and  pan- 
creatic fluid  regurgitated  into  the  stomach  through 
the  pylorus  for  the  fourteen  weeks  during  which  the 
patient  survived  the  accident,  without  there  being 
any  signs  of  vicious  circle  (5). 

(e)  The  formation  of  a  spur  at  the  point  of  anas- 
tomosis. This,  by  preventing  the  onward  passage 
of  the  stomach  contents,  may  undoubtedly  be  a  cause, 
but  it  will  not  occur  if  the  technique  described  on 
p.  152  is  followed. 

(/)  Acute  angulation  of  the  jejunum  beyond  the 
anastomotic  opening ;  a  well-recognised  cause,  readily 


172  CxlNCER   OF    THE    STOMACH 

avoided  by  one  or  two  anclior  sutures  beyond  tlie 
opening. 

(g)  Pouting  valves  of  mucous  membrane.  This 
may  be  a  cause_,  but  it  is  readily  avoided  by  the 
proper  application  of  the  marginal  suture  securing 
apposition  of  the  intestinal  to  the  gastric  mucous 
membrane. 

(/i)  Compression  of  the  colon  by  the  jejunal  loop 
in  the  anterior  operation   (Doyen). 

(i)  Adhesions  forming  subsequent  to  the  operation 
leading  to  constriction  of  the  distal  arm  of  the 
jejunum,  as  in  a  case  under  my  care  in  1901,  which 
Avas  operated  on  six  months  later  and  cured  by  the 
division  of  a  band  crossing  the  distal  jejunal  loop  (6). 

It  will  thus  be  seen  that  the  causes  of  the  vicious 
circle  are  avoidable,  and  the  complication  should 
therefore  seldom,  if  ever,  occur  ;  and,  in  fact,  since 
recosrnisinq;  the  cause  in  1901  I  have  never  seen  a 
case  of  regurgitant  vomiting  in  my  practice. 

Treatment  of  the  xicious  circle. — This  should  be 
preventive  by  accuracy  of  technique,  and  if  the  fol- 
lowing points  are  observed  the  vicious  circle  Avill  not 
occur  : 

(a)  Accurate  union  of  the  mucous  margins  of  the 
stomach  and  jejunum. 

[h)  Securing  the  anastomotic  opening  at  or  near 
the  lower  border  of  the  stomach. 

(c)  Applying  one  or  more  anchor  sutures  beyond 
the  point  of  anastomosis. 


GASTRO-ENTEEOSTOMY  173 

{d)  Bringing  the  distal  loop  of  jejunum  over  to  the 
right  of  the  spine  in  arranging  the  peritoneal  toilet 
before  closing  the  abdomen. 

[e)  Making  the  anastomosis  in  the  posterior  opera- 
tion either  without  a  loop  or  with  a  very  short  interval 
between  the  anastomosis  and  the  jejunal  flexure. 

(/)  In  the  anterior  operation  the  loop  must  not  be 
made  too  short  so  as  to  compress  the  colon. 

If  the  technique  has  been  faulty^  and  unfortunately 
regurgitant  vomiting  should  occur^  w4iat  can  be  done  ? 

(a)  Raise  the  head  and  shoulders  so  as  to  prop  up 
the  patient  in  a  semi-recumbent  posture. 

(h)  Wash  out  the  stomach  and  repeat  it  if  neces- 
sary. 

(c)  Feed  by  the  bow^el  and  stop  mouth-feeding  for 
a  time. 

{d)  Give  small  doses  of  calomel  in  repeated  doses, 
followed  by  enemata_,  to  try  to  secure  a  movement  of 
the  bowels. 

(e)  If  these  fail,  do  not  wait  too  long  before  re- 
opening the  abdomen  and  performing  entero-anas- 
tomosis — an  effectual  method  of  treatment. 

(2)  Suhsequcnt  contraction  of  the  anastomotic  ojicn- 
ing. — Although  there  may  be  moderate  contraction 
of  the  new  opening,  both  in  cases  Avhere  the  stomach 
is  greatly  dilated  before  operation  and  in  those  where 
the  pylorus  is  patent  at  the  time  of  operation,  yet  if 
the  anastomotic  opening  be  made  sufficiently  large, 
not  under  2  in.,  and  the  union  of  mucous  membrane 


174  CANCER   OF   THE    STOMACH 

to  mucous  membrane  be  efficiently  performed^  con- 
traction to  a  serious  extent  will  not  be  likely  to  occur. 
I  have  always  found  the  opening  to  be  patent  where 
I  have  at  long  periods  subsequent  to  operation  had 
to  operate  again  for  some  other  cause. 

There  have  been  a  number  of  cases  recorded  (14) 
in  which  closure  of  the  artificial  opening  has  occurred 
within  a  short  time  after  the  use  of  Laplace's  forceps, 
and  in  others  at  a  later  time  after  the  use  of  the 
Murphy  button,  and  after  the  employment  of  Sennas 
plates. 

Dr.  W.  J.  Mayo  (12)  in  a  paper  read  before 
the  American  Surgical  Association  in  June,  1902, 
reported  four  cases  in  which  contraction  at  the  site 
of  anastomosis  took  place.  These  all  followed  the 
use  of  the  Murphy  button  and  occurred  in  cases 
where  the  pjdorus  was  not  occluded. 

In  operations  for  ulcer  of  the  stomach  it  seems 
highly  probable  that  the  reason  for  want  of  relief  in 
some  of  the  cases  has  been  owing  to  the  anastomotic 
opening  being  made  of  too  small  a  size,  under 
which  circumstances  any  subsequent  slight  contrac- 
tion becomes  of  serious  moment.  This  was  demon- 
strated satisfactorily  by  Mr.  H.  J.  Paterson  in  his 
Hunterian  Lectures  delivered  at  the  College  of 
Surgeons  in  1906    (13). 

(3)  Peptic  ulcer  of  the  jejunum. — The  subject  of 
peptic  ulcer  is  an  extremely  interesting  one  that  has 
given  rise  to  much  speculation  aud  to  many  theories. 


GASTRO-ENTEROSTOMY  175 

In  the  stomach  it  is  extremely  common^  in  the 
duodenum  probably  much  more  frequent  than  hitherto 
supposed^  but  in  the  jejunum  it  is  generally  acknow- 
ledged to  be  very  rarely  found  ;  in  fact  it  was  only 
in  1899  that  Braun  first  described  the  formation  of 
peptic  ulcer  in  the  jejunum  of  man,  and  although 
the  subject  has  since  received  attention  in  Germany 
by  Hahn,  Kausch,  Korte,  and  others,  my  own  case 
reported  before  the  Royal  Medical  and  Chirurgical 
Society  on  April  12th,  1904,  was  the  first  described 
in  English  literature.  In  that  paper  I  referred  to 
several  cases,  but  I  know  that  Mikulicz  has  since 
reported  other  cases,  and  several  additional  ones 
were  collected  by  Mr.  Paterson  in  his  Hunterian 
Lectures. 

As  all  of  these  cases  were  perforating  ulcers,  it 
almost  goes  without  saying  that  there  must  be  many 
more  that  have  existed  unrecognised,  and  probably 
others  that  may  have  caused  death  by  abscess,  and 
in  other  ways  in  which  the  adhesions  and  other 
complications  have  so  obscured  the  parts  that  even 
an  autopsy  has  failed  to  elucidate  the  true  nature  of 
the  disease. 

The  true  cause  of  peptic  ulcer,  whether  gastric, 
duodenal,  or  jejunal,  is  probably  a  mild  form  of 
sepsis  leading  to  gastritis  and  excess  of  free  HCl  in 
the  gastric  juice.  Traumatism,  either  by  coarse  food 
or  through  external  injury,  and  interference  with  the 
circulation    in    the    bowel    have    been     assigned    as 


176  CANCER   OF   THE   STOMACH 

causes,  but  without  what  seems  to  me  adequate 
reasons. 

Peptic  ulcer  is  distinctly  one  of  the  sequelae  to  be 
reckoned  with  after  gastro-enterostomy.  An  analysis 
of  the  cases  shows  it  to  occur  more  frequently  after 
the  anterior  than  the  posterior  operation. 

As  excess  of  free  hydrochloric  acid  is  not  found 
in  cancer  of  the  stomach  (except  in  ulcus  carcino- 
matosum)  it  is  hardly  likely  that  peptic  ulcer  of  the 
jejunum  will  be  found  after  gastro-jejunostomy  for 
malignant  disease,  and  so  far  as  I  know  all  the 
reported  cases  have  occurred  after  operations  for 
simple  disease,  especially  ulcer.  Nevertheless  it  is 
necessary  to  notice  it  here  as  one  of  the  complica- 
tions that  may  be  met  with. 

As  regards  the  frequency  of  peptic  jejunal  ulcers, 
out  of  nearly  300  posterior  gastro-enterostomies 
which  I  have  personally  performed  I  have  not  had 
one  example. 

My  single  case  occurred  after  an  anterior  gastro- 
enterostomy, 1  out  of  30  that  I  have  performed ; 
and  Kausch  reported  2  out  of  160  gastro-entero- 
stomies performed  in  Professor  Mikulicz\s  clinic, 
both    being   after    anterior   gastro-enterostomy. 

Out  of  the  19  cases  reported,  the  anterior  operation 
had  been  done  in  14,  the  posterior  in  2,  and  the 
Y  operation  of  Roux  in  1  ;  but  whereas  in  the  2 
cases  of  peptic  ulcer  occurring  after  the  posterior 
operation,  perforation  was  followed  by  general  perito- 


GASTIIO-ENTEROSTOMY  1 77 

nitis,  in  the  14  anterior  operations  the  peritonitis  was 
limited  in  9  and  diffuse  only  in  5. 

The  symptoms  in  my  case  were  evidently  chiefly 
referable  to  the  perigastritis  and  the  extensive  ad- 
hesionS;  and  although  there  was  intense  and  agonising- 
pain  at  times^  it  seemed  to  bear  no  relation  to  food  : 
exquisite  tenderness  over  the  upper  abdomen  was  a 
marked  feature  of  the  case. 

Treatment  of  peptic  jejunal  ulcer. — In  the  cases  of 
gastric  ulcer  that  have  failed  to  yield  to  medical 
treatment^  and  in  which  gastro-enterostomy  has  been 
performed^  I  fear  that  we  have  not  properly  grasped 
the  fact  that  the  operation  is_,  though  an  important 
one^  still  only  an  incident  in  the  treatment^  which 
ought  to  be  continued  on  general  lines  for  some  time 
longer^  or  until  good  health  is  again  established. 
Greater  attention  to  oral  asepsis  and  to  the  gastric 
condition  of  hyperchlorhydria  subsequent  to  operation 
is  advisable,  and  in  this  way  the  very  serious  compli- 
cation of  peptic  ulcer  in  the  jejunum  and  relapses  in 
gastric  ulcer  might  be  prevented. 

In  all  the  cases  reported,  perforation  associated 
with  acute,  subacute,  or  chronic  symptoms,  has  oc- 
curred ;  hence  there  can  be  no  question  as  to  the 
desirability — nay,  as  to  the  absolute  necessity — of 
operation,  which  ought  not  to  be  delayed  too  long. 
When  the  abdomen  is  opened  the  treatment  will  de- 
pend on  the  condition  found.  If  perforation  has 
occurred  into  the  general  peritoneal  cavity  the  con- 

12 


178  CANCER   OF   THE    STOMACH 


Fig.  20 — 1.  Diagram  of  condition  found  on  separating  adhe- 
sions, May,  1903,  shoAving  perforation.  2.  Diagram  of 
portion  of  nicer  adherent  to  and  detached  from  anterior 
abdominal  wall.  3.  Diagram  of  portion  of  intestine 
excised.  4.  Diagram  of  anastomosis  performed  after  the 
enterectomy.  5.  Size  of  bobbins  used.  These  five  figures 
are  from  page  3-1-i,  vol.  Ixxxvii,  Mcd.-CMr.  Trans. 


GASTRO-ENTEROSTOMY  179 

dition  will  be  one  of  the  utmost  peril^  and  only 
capable  of  relief  by  immediate  cleansing  of  the 
peritoneum  and  closure  of  the  opening,  or  by  excision 
of  the  ulcer,  with  subsequent  suture. 

Though  peptic  ulcer  of  the  jejunum  is  less  frequent 
after  posterior  gastro-enterostomy,  only  two  cases 
having  been  recorded,  when  it  does  occur  it  is  more 
likely  to  be  acute  and  not  to  be  limited  by  adhesions. 

If,  as  in  the  greater  number  of  cases,  adhesions 
have  formed,  the  condition  will  be  less  acute,  although 
very  distressing,  from  the  associated  pain  due  to  peri- 
gastritis and  adhesions.  It  will  be  necessary  to 
detach  adhesions  and  to  repair  the  perforation,  but 
probably  in  the  greater  number  of  cases,  an  excision 
of  the  portion  of  intestine  involved  and  the  perform- 
ance of  a  Roux's  operation  will  give  the  best  results. 
In  my  case,  which  occurred  three  years  and  four 
months  after  an  anterior  gastro-enterostomy,  I  excised 
the  portion  of  jejunum  involved  and  performed  a 
Roux^s  operation  as  shown  in  the  accompanying  dia- 
grams. The  operation  was  followed  by  recovery. 
I  have  operated  on  two  other  cases  of  jejunal  ulcer 
after  gastro-enterostomy  performed  elsewhere,  but  in 
neither  of  these  cases  had  perforation  taken  place  : 
both  recovered. 

(4)  Chest  complications. — Pneumonia  or  pleurisy 
are  said  to  have  followed  operation  on  the  stomach 
with  greater  frequency  than  in  any  other  abdominal 
operations,  the  reason  given  being  the  difficulty  of 


180  CANCER   OF   THE    STOMACH 

expanding  tlie  lungs  in  consequence  of  fixation  of  tlie 
ribs  subsequent  to  operation. 

My  experience  has  not  borne  out  this  observation^ 
for  I  liave  found  cliest  complications  to  occur  very 
seldom  in  my  stomach  operations,  certainly  not  more 
frequently  than  after  any  other  laparotomy.  This 
may,  perhaps,  arise  from  the  facts  that  I  always  have 
the  patient  enveloped  in  a  gamgee  tissue  suit  so  as 
to  avoid  chilling  during  operation ;  have  the  head 
and  shoulders  well  propped  up  by  pillows  after 
operation,  and  that  chloroform  is  usually  the  anaes- 
thetic employed.  Moreover,  in  an  old  subject  it  is 
always  desirable  to  turn  the  patient  on  the  side  from 
time  to  time,  so  as  to  avoid  hypostatic  congestion  of 
the  bases  of  the  lungs. 

(5)  Perforation,  owing  to  icant  of  union  at  the  point 
of  anastomosis. — This  is  an  extremely  serious  compli- 
cation, and  probably  almost  universally  fatal.  I  have 
never  known  it  to  occur  after  union  by  suture,  but 
once  saw  it  happen  some  years  ago  in  one  of  the  few 
cases  in  which  I  employed  the  Murphy  button,  and 
Dr.  W.  J.  Mayo  has  reported  two  cases  that  occurred 
under  similar  conditions.  In  one  the  accident  fol- 
lowed an  epileptic  seizure  on  the  ninth  day,  in  the 
other  on  the  seventh  day  after  gastro-enterostomy  for 
malignant  disease  of  the  pylorus. 

Want  of  union  used  to  be  less  rare  when  moribund 
patients  were  operated  on,  but  it  is  seldom  seen  now 
except  when   the  Murphy  button  has  been  used,  in 


GASTRO-ENTEROSTOMY  181 

wliicli  case  there  is  nothing  to  prevent  extravasation 
if  union  be  delayed  beyond  the  first  few  days ; 
whereas^  if  union  is  effected  by  a  double  line  of 
sutures_,  delayed  healing,  if  not  too  long*,  is  not 
serious. 

Muniford  described  a  case  of  separation  of  the 
viscera  in  a  case  of  posterior  gastro-enterostomy 
performed  by  the  no-loop  method,  which  he  ascribed 
to  a  short  ligament  of  Treiz,  so  that  when  the 
dilated  stomach  contracted  it  forcibly  dragged  on 
the  attached  jejunum  and  led  to  separation. 

(6)  Adhesions  s-iihseqnent  to  gastro-ejiferostomy. — 
Perigastritis,  or  adhesive  peritonitis,  at  a  distance 
from  the  site  of  operation  is  probably  uncommon  after 
aseptic  operations,  though  adhesions  may  result  from 
the  use  of  strong  antiseptics,  or  if  ha^mostasis  is 
imperfect.  Adhesions,  the  result  of  ulcer  and  cancer 
are  extremely  common,  and  I  have  seen  them  so  ex- 
tensive that  it  was  almost  impossible  to  find  any 
healthy  portion  of  the  stomach  to  Avhich  the  jejunum 
might  be  applied.  Under  these  circumstances,  a 
posterior  gastro-enterostomy,  on  account  of  oblitera- 
tion of  the  lesser  peritoneal  cavity,  may  be  impossible, 
and  it  is  better  to  perform  a  Roux's  anterior  Y  opera- 
tion. In  one  case  of  this  kind,  though  an  immediate 
successful  result  was  obtained  by  a  Roux's  operation, 
the  symptoms  recurred  some  months  later,  evidently 
due  to  the  formation  of  further  adhesions.  In  another 
case  that  came  under  my  care  in  1891  I  had  to  operate 


182  CANCER    OF   THE    STOMACH 

for  bilious  vomiting  that  came  on  some  months  after 
gastro-enterostomy^  wliich  I  found  on  exploration 
was  caused  by  a  band  stretching  from  the  transverse 
colon  and  compressing  the  efferent  jejunal  loop^ 
relief  being  given  by  the  division  of  the  band  and 
an  entero-anastomosis. 

(7)  Internal  herniw. — Internal  hernise  after  gastro- 
enterostomy may  occur  under  three  conditions  : 

[a)  The  passage  of  small  intestine  through  the 
loop  formed  above  the  junction  of  the  jejunum  and 
stomach.  This  condition  is  only  likely  to  occur  after 
the  anterior  operation^  as  in  a  case  reported  hj  Dr. 
W.  J.  Mayo  (12)  in  the  AnnaJs  of  Surgery,  1902. 
The  accident  happened  a  year  after  an  anterior 
gastro-enterostomy. 

(b)  There  are  several  cases  on  record  of  the  passage 
of  small  intestine  through  the  slit  in  the  meso-colon 
made  for  the  anastomosis  in  posterior  gastro-ente- 
rostomy. A  case  of  this  kind  occurred  in  one  of  Mr. 
Moynihan^s  ]3atients,  who  died  on  the  tenth  day  of 
acute  intestinal  obstruction^  when  a  great  part  of  the 
small  intestines  were  found  in  the  lesser  peritoneal 
cavity  (7). 

In  a  second  case  occurring  in  his  practice  he  opened 
the  abdomen  and  reduced  the  hernia,  the  jDatient  re- 
covering. 

The  accident  may  be  avoided  by  not  making  the 
opening  too  large  and  by  suturing  with  tAVO  or  three 
Pagenstecher^s  sutures  the  margin  of  the  opening  in 


GASTR0-ENTER08T0MY  183 

the  meso-colon  to  tlie  line  of  junction  of  the  stomach 
and  jejunum. 

Mr.  A.  E.  Barker  and  Mr.  W.  Alexander  have 
described  cases  of  this  accident  (8). 

(r)  Mr.  Barker  (9)  has  recorded  a  case  in  which 
two  years  after  a  posterior  gastro-enterostomy  nearly 
the  Avhole  of  the  small  intestines  passed  over  the 
afferent  loop  and  became  strangulated. 

Dr.  H.  M.  W.  Gray  (15)  found,  in  a  case  of  acute 
obstruction  after  gastro-enterostomy  in  which  he  re- 
opened the  abdomen  on  the  seventh  day  subsequent 
to  the  original  operation,  that  practically  the  whole 
of  the  small  intestine  had  insinuated  itself  from  left 
to  right  through  the  ring  formed  b}^  the  peritoneum 
of  the  under  layer  of  the  meso-colon,  lining  the  pos- 
terior abdominal  wall  and  forming  the  upper  layer 
of  the  mesentery,  the  ring  being  completed  anteriorly 
by  the  gastro-jejunal  junction.  It  was  easily  pulled 
back  and  the  ring  closed  by  suturing  the  under  layer 
of  the  meso-colon  to  the  upper  layer  of  the  mesentery 
to  prevent  recurrence  of  the  hernia.  The  patient 
recovered. 

In  the  operation  I  have  described  such  an  accident 
could  not  occur,  as  there  is  no  long  jejunal  loop. 

(8)  Death  from  asthenia. — In  the  eighties  and  early 
nineties  it  was  considered  absolutely  essential  to  ab- 
stain from  feeding  by  the  mouth  after  any  stomach 
operation,  and  as  gastric  operations  were  then  always 
delaj^ed  until  the  patient  was  extremely  weak,  it  fol- 


184  CANCER    OF   THE    STOMACH 

lowed  as  a  necessary  consequence  that  asthenia.  01%  in 
other  wordSj  starvation,  was  a  real  danger. 

Asthenia  from  this  cause  is  now  seldom  seen,  as 
feeding  is  begun  immediately  the  patient  has  recovered 
from  the  anaesthetic.  In  my  own  practice  I  do  not 
hesitate  to  let  the  patients  have  liquid  or  semi-liquid 
nourishment  in  small  quantities  every  half  hour  as 
soon  as  they  can  take  it,  and  seeing  that  in  gastro- 
enterostomy anaesthetic  vomiting  does  not  occur,  the 
patient  is  usually  able  to  have  some  food  within  four 
hours  of  the  operation,  this  being  supplemented  by 
nutrient  enemata  of  normal  saline  solution  containing 
liquid  peptonoids  and  brandy.  (See  after-treatment 
and  feeding  after  gastro-enterostomy,  p.  168.) 

(9)  Haemorrhage. — Haemorrhage  as  a  cause  of  death 
after  gastro-enterostomy  is  not  likely  to  occur  as  the 
result  of  the  operation  itself,  as  the  continuous  suture 
applied  through  the  whole  thickness  of  the  margins 
of  the  anastomotic  opening  acts  as  an  efficient  com- 
press to  the  vessels.  It  may,  however,  occur  from 
ulcer  or  cancer  just  as  it  might  have  happened  had 
no  operation  been  done  in  such  cases.  The  administra- 
tion of  adrenalin,  the  abstention  from  mouth-feeding, 
and  the  injection  of  lactate  of  calcium  under  the  skin 
or  by  rectal  enemata  will  be  found  useful,  and  the 
treatment  will  be  as  in  other  cases  of  haBmatemesis 
or  melasna.  Should  the  bleeding  persist,  the  question 
of  further  operation  will  arise,  in  order  to  discover 
and  treat  the  bleeding  points. 


rTASTRO-ENTEROSTOMY  185 

The  after-results  of  gastro-jejunostomy. —  (1)  In  con- 
sidering tlie  varions  complications,  it  seems  quite 
definitely  proved  that  the  use  of  the  Murphy  button 
is  attended  with  uncertain  results,  both  on  account 
of  the  subsequent  tendency  to  contraction  of  the 
anastomotic  opening  and  the  retention  of  the  metal 
instrument  in  the  stomach. 

(2)  If  the  anastomotic  opening  be  made  of  too 
small  a  size  it  is  apt  to  prove  unsatisfactory  and  to 
lead  to  relapse. 

(3)  The  methods  which  do  not  secure  continuit}^ 
of  the  mucous  membranes  of  the  anastomosed  viscera 
are  apt  to  be  followed  by  undue  contraction  or  even 
complete  closure  of  the  new  passage. 

(4)  The  risk  of  peptic  jejunal  ulcer,  even  after  all 
the  methods  that  have  been  described,  is  probably 
under  2  per  cent.,  but  if  the  posterior  operation  be 
performed  and  the  anastomotic  opening  be  made 
sufficiently  large,  the  .risk  is  hardly  appreciable, 
certainl}^  nothing  like  1  per  cent. 

(5)  If  the  method  of  union  by  suture  that  I  have 
described  be  performed,  and  the  opening  be  made  of 
sufficient  size,  considerably  over  90  per  cent,  of 
patients  suffering  from  pyloric  stenosis  of  a  simple 
character,  or  from  gastric  ulcer,  w411  be  completely  and 
permanently  relieved  of  their  symptoms,  and  those 
suifering  from  cancer  should  derive  considerable  relief. 
I  have  had  cancer  cases  to  survive  for  over  two  years, 
and  to  lose  all  pain  and  discomfort  for  long  periods. 


186  CANCER   OF   THE    STOMACH 

(6)  As  a  number  of  patients  suffering  from  non- 
malignant  diseases  have  regained  their  normal  weight 
and  lived  for  many  years  in  good  health — some  even 
for  twenty  years — there  seems  to  be  no  reason  to 
suppose  that  the  operation  of  gastro-enterostom}- 
jier  f^e  tends  to  shorten  life. 

Chemico-pathological  evidence.  —  The  experiments 
performed  by  Joslin  (10)  were  carried  out  on  patients 
Avho  had  had  gastro-enterostomy  performed  for 
cancer  of  the  pylorus.  His  conclusions^  therefore, 
which  seem  to  prove  that  the  operation  leads  to  a 
marked  diminution  of  absorption  of  nitrogenous 
foods  as  well  as  of  fats  and  hydro- carbons,  cannot 
be  taken  seriously,  as  cancer  itself  is  capable  of 
producing  these  results.  Moreover,  Mr.  H.  J. 
Paterson  and  Dr.  Francis  Goodbody  (11)  carried  out 
a  series  of  experiments  on  four  patients  in  whom 
gastro-enterostomy  had  been  performed  for  simple 
disease  of  the  stomach,  which  proved  very  clearly 
that  metabolism  is  practically  unaffected  after 
gastro-jejunostomy,  as  in  none  of  the  cases  did  the 
unabsorbed  nitrogen  amount  to  more  than  2  per  cent, 
above  the  amount  usually  passed  in  the  f^ces  by  a 
healthy  individual,  while  the  amount  of  fat  passed 
unabsorbed  did  not  on  any  occasion  exceed  I'l  per 
cent,  of  the  fat  taken  in  the  food,  that  is,  just  over 
2  per  cent,  above  the  amount  usually  passed  in  the 
fa9ces  by  a  healthy  man. 


GASTRO-ENTEROSTOMY  187 


REFERENCES. 

1.  Mayo,    W.   J.,   "  The   Technique   of  Gastro-jejunostomy." — 
Annals  of  Surgery,  April,  1906. 

2.  Yon    Eiselsberg. — Trans,    of  Internat.    Congress   of  Surgery, 
Brussels,  1905. 

3.  Mumford. — Annals  of  Surgery,  190G,  p.  88. 

4.  Dastre.— ^rc?iw/ur  FhysioL,  1890,  p.  316. 

5.  Moynihsin.— Brit.  Med.  Journ.,  1901,  p.  1136. 

0.  Mayo  Robson. — Diseases  of  the  Stomach,  3rd  edition,  p.  236. 

7.  Moynihan.— J5ri^.  Med.  Journ.,  1903,  vol.  ii,  p.  1592. 

8.  Barker  and  Alexander. — Lancet,  February  24th,  1906,  p.  497. 

9.  Barker,  A.  E. — Lancet,  Novexnber  5th,  1904,  p.  1277. 

10.  io%\\n.— Berlin,  klin.  Wochensch.,  1897,  p.  1047. 

11.  Patterson,  H.  J.,  and  Francis  Goodbody. — Lancet,  February 
24th,  1906,  p.  495. 

12.  Mayo,  W.  J.,  American   Surgical  Association,  June,   1902. 
— Annals  of  Surgery,  1902. 

13.  Paterson,  "  Hunterian  Lectures." — Lancet,  1906. 

14.  Mayo  Robson  and  Moynihan.— Diseases  of  the  Stomach,  2nd 
edition,  Bailliere,  Tindall  and  Cox. 

15.  Gray. — Lancet,  August  29th,  1904. 


CHAPTER    XI 
GASTROSTOMY 

TiiE  operation  of  gastrostomy  is  designed  to 
make  an  artificial  opening  in  the  stomachy  tlirongli 
wliich  a  patient  may  be  fed  wlien^  for  various 
reasons,  food  cannot  be  taken  in  the  ordinary  way. 
It  was  first  suggested  by  Egeberg  in  1837,  but  was 
first  carried  out  by  Sedillot  in  1849.  In  1875 
Sydney  Jones  performed  the  operation,  and  the 
patient  survived  sixteen  days,  but  Yerneuil,  in  1876, 
had  a  patient  to  survive  for  sixteen  months. 

Survival  after  gastrostomy  for  cancer  of  the 
oesophagus  does  not  often  exceed  a  few  months, 
though  I  have  had  a  patient  to  live  for  a  little  over 
a  year. 

After  the  operation  for  simple  stenosis,  life  may, 
however,  be  prolonged  for  years  ;  one  of  ni}' 
patients  is  living  seven  years  later,  and  I  have 
heard  of  one  surviving  for  ten  years,  all  the  food 
being  taken  through  the  artificial  opening. 

Indications. —  (1)  Cancer  of  oesophagus  or  pharynx, 
causing  obstruction  to  swallowing  of  food. 


GASTEOSTOMY  189 

(2)  Simple  stenosis  of  pliaiynx  or  Gesopliagus_, 
after  swallowing  of  caustic  fluids  or  from  syphilis  or 
other  cause^  which  cannot  be  kept  patent  by  bougies. 

(3)  Cancer  of  cardiac  end  of  stomach  leading  to 
difficulty  of  entrance  of  food  into  the  stomach, 

(4)  It  has  been  suggested  as  a  palliative  proce- 
dure in  extensive  cancer  within  the  mouth  or 
pharynx  in  which,  although  swallowing  of  food  is 
possible,  it  can  only  be  accomplished  with  great  pain. 

The  operation  is  most  useful,  but  was  for  long- 
held  in  disrepute  for  two  reasons  :  First,  from 
the  custom  to  delay  gastrostomy  until  the  patient 
was  in  the  last  stage  of  exhaustion,  when  naturally 
the  mortality  was  very  great ;  and  secondly,  when  a 
direct  opening  into  the  stomach  used  to  be  made, 
leakage  of  the  stomach  contents  with  consequent 
irritation  of  the  skin  around  the  fistula  made  the 
remainder  of  life,  in  case  of  survival,  so  miserable 
that  it  was  thought  to  be  scarcely  worth  while  to 
recommend  it. 

With  improved  technique,  however,  the  operation 
is  rendered  both  safe  and  efficient. 

The  operation  I  am  accustomed  to  perform  is  very 
simple,  and  only  occupies  a  few  minutes ;  if  needful 
it  can  be  done  under  local  anaesthesia  (1).  It  is  a 
modification  of  the  Ssabanejew-Franck  operation,  and 
has  given  me  very  good  results — twenty-three  re- 
coveries out  of  twenty-four  operations  performed 
since  1897. 


190 


CANCER    OF   THE   STOMACH 


A  vertical  incision  of  about  IJ  in.  is  made  over  tlie 
outer  third  of  tlie  left  rectus  abdominis^  commencing 
f  in.  below  tlie  costal  margin  ;  tlie  fibres  of  tlie  rectus 
are  separated;  but  not  divided^,  to  the  extent  of  the 


Fig.  21. — Gastrostomy. 


(France's    method    modified    by    the 
author.) 


incision_,  and  the  posterior  part  of  the  rectus  sheath 
and  peritoneum  are  divided  together^  the  opening 
being  1  in.  in  length.  A  portion  of  the  cardiac  end 
of  the  stomach  is  then  brought  up  through  the  wound 


GASTROSTOMY 


191 


and  held  forward  by  an  assistant  until  four  sutures 
are  inserted  into  the  base  of  the  cone  by  means  of  a 
curved  intestinal  needle  so  as  to  fix  the  visceral 
peritoneum  of  the  stomach  to  the  edges  of  the  parietal 


Fig.  22. — Gastrostomy.      (Franck's  mothod  modified.) 

peritoneum.  A  transverse  incision  of  ^  ii^-  is  then 
made  through  the  skin  1  in.  above  the  upper  end  of 
the  first  cut,  and  by  means  of  a  blunt  instrument, 
such  as  the  handle  of  a  scalpel,  the  skin  is  under- 
mined so  as  to  connect  the  two  openings  beneath  the 


192 


CANCEII   OF   THE    STOMACH 


bridge  of  skin  and  subcutaneous  tissue.  A  closed 
pair  of  pressure  forceps  is  introduced  tlirougli  the 
upper  incision  as  far  as  tlie  projecting  part  of  tlie 
stomacli;  and  made  to  grasp  the  most  prominent  part^ 


Fig.  23. — Gastrostomy.     (Frauck's  metliod  modified.) 

which  it  draws  up  to  and  beyond  the  surface  of  the 
second  opening,  where  it  is  retained  by  means  of  two 
hare-lip  pins.  It  should  just  fill  the  opening,  and 
should  require  no  sutures.  The  lower  opening  is  now 
closed  b}^  two  or  three  silkworm-gut  sutures,  or  by  a 


GASTROSTOMY  193 

continuous  stitch,  and  by  Micliers  clips,  and  the 
edges  are  dried  and  covered  with  collodion  and 
gauze.  The  stomach  is  opened  at  once  by  a  tenotomy 
knife  introduced  between  the  jDins.  After  opening 
the  stomach,  a  Jacques  catheter,  from  a  No.  8  to 
No.  12,  is  inserted,  to  which  a  piece  of  rubber  tubing- 
is  fixed,  and  by  means  of  a  funnel  the  patient  can  at 
once  be  fed  with  warm  milk  and  egg,  or  whatever 
liquid  may  be  thought  desirable.  The  catheter  may 
be  left  in  position  for  a  few  days,  after  which  it  is 
easy  to  insert  it  whenever  a  meal  is  required. 

E.  J.  Sennas  method  (2)  :  The  stomach  being  ex- 
posed, an  incision  about  1  in.  in  length  is  made  into 
its  cavity  as  near  the  cardia  as  possible,  and  midway 
between  the  greater  and  lesser  curvatures.  A  tube 
equal  to  a  No.  12  or  No.  14  catheter  is  now  intro- 
duced into  the  stomach  and  there  fixed  by  a  suture, 
which  includes  the  cut  edge  of  the  stomach  and  the 
side  of  the  tube.  In  order  to  infold  the  tube  in  the 
stomach  wall,  a  purse-string  suture  is  passed  round 
the  tube  at  a  distance  of  |  in.  from  it.  The  tube  is 
pushed  inwards  towards  the  stomach  cavity  while 
the  suture  is  tied.  A  second  purse-string  suture, 
and  then  a  third^  are  passed  and  tied  in  the  same 
manner.  The  result  is  that  the  tube  lies  in  a  funnel- 
shaped  inverted  portion  of  the  anterior  wall  of  the 
stomach,  and  is  there  fixed  by  the  sutures  placed  one 
above  the  other.  The  stomach  is  now  fixed  to  the 
anterior   abdominal   wall   by  a   suture    above   and  a 

13 


194 


CANCER   OF   THE    STOMACH 


suture  below  the  tube,  and  the  abdommal  incision  is 
closed  in  the  usual  manner.      The  advantao-e  of  this 


Fig.  24. — Gastrostomy.      (Senu's  method.) 

method  over  Franck's,  or  its  modification,  lies  in  the 
fact  that  as  the  portion  of  the  anterior  stomach  wall 


GASTROSTOMY  195 

used  for  the  purpose  of  effecting  valvular  action  is 
pushed  inwards  instead  of  being  dragged  outwards, 


Fig.  25.— Gastrostomy.     (Witzel's  method.) 

a  larger  cavity  is  left  for  the  reception  of  food,  and 
the  area  of  the  gastric  mucosa  brought  into  contact 
with   the   food  is  therefore   more   extensive.      I   can 


196  CANCER   OF   THE    STOMACH 

recommend  this  method   as   at   once   easy,  safe,  and 
efficient. 

Witzel^s  method  (3)  :  An  incision,  parallel  to  the 
costal  margin,  is  made  until  the  rectus  muscle  is 
reached.  The  fibres  of  the  muscle  are  split  vertically 
and  the  peritoneum  opened.  The  stomach  is  exposed 
and  drawn  out  of  the  wound  ;  a  small  incision  is  made 
into  the  stomach,  a  tube  introduced  and  fixed  by  a 
single  catgut  suture.  The  tube  is  then  laid  upon 
the  stomach  wall  for  a  distance  of  2  in.,  or  rather 
more,  and  a  gutter  is  made  for  it  by  raising  up  a 
fold  on  each  side  and  stitching  the  folds  over  the 
tube.  The  tube  then  opens  into  the  stomach  in  the 
same  manner  as  the  ureter  opens  into  the  bladder. 
The  stomach  is  fixed  to  the  abdominal  wall  by  two  or 
three  sutures.  Mikulicz  and  Helferich  have  shown 
that  after  the  lapse  of  a  few  months  the  oblique 
passage  for  the  tube  becomes  a  direct  one,  the  inner 
orifice  lying  behind  the  outer. 

Kader^s  method  (4)  :  The  stomach  is  exposed 
through  Fenger^s  incision,  a  cut  is  made  into  it,  and 
a  tube  introduced  and  fixed  by  a  single  catgut 
stitch.  Two  parallel  folds  of  the  stomach  are  then 
raised  up,  one  on  each  side  of  the  tube,  and  their 
summits  are  sutured  by  two  or  three  Lembert  sutures 
above,  and  the  same  number  below  the  tube.  The 
sutures  are  cut  short.  Two  similar  parallel  folds 
are  again  raised  up  and  again  stitched,  and  if 
necessary    a    third    tier   is   added.      A  most  efficient 


GASTROSTOMY 


197 


Fig.  26.— Gastrostomy.     (Kacler's  method.) 


198  CANCER   OF   THE    STOMACH 

valve  is  thus  formed.  The  stomach  is  fixed  by  one 
or  two  sutures  to  the  anterior  abdominal  wall. 

A.  Depage  (4)  devised  the  following  operation, 
which  he  successfully  performed  in  a  case  of  cancer 
of  the  upper  part  of  the  oesophagus  when  solid  food 
could  not  be  taken  :  A  vertical  incision  7  or  8  cm. 
long  is  made  a  little  to  the  left  of  the  middle  line 
and  at  the  seat  of  election.  After  opening  the 
abdominal  cavity,  a  portion  of  the  stomach  is  drawn 
out  and  separated  from  the  peritoneal  cavity  by  a 
continuous  suture  which  unites  the  wall  of  the-  organ 
to  the  edge  of  the  peritoneum.  A  flap  with  its 
base  upward  is  then  cut  out  of  the  anterior  wall  of 
the  stomach.  This  can  be  easily  done  by  pinching 
up  a  piece  of  the  wall  between  pressure  forceps  and 
cutting  along  the  blades.  The  flap  is  then  turned 
upward  and  the  incision  in  the  stomach  is  closed 
by  a  continuous  suture,  carried  first  only  through 
the  mucous  coat.  The  serous  layer  is  sutured  in  the 
same  way.  Each  of  the  sutures  is  continued  on  to 
the  flap,  which  is  in  this  way  transformed  into  a 
canal.  The  canal  thus  made  is  fixed  to  the  abdo- 
minal wall,  or  if  long  enough  it  may  be  drawn 
through  a  parietal  tunnel  near  to  the  xiphoid 
cartilage.  The  abdominal  incision  is  then  sutured 
and  a  sound  is  introduced  into  the  canal,  and  may 
be  left  there  or  inserted  before  each  meal. 

This  somewhat  complicated  operation  is  more 
difficult  to  perform,   and    at  the   same    time   is  not 


GASTROSTOMY 


199 


Fig.  27. — Depage's    Gastrostomy. 
a,  the  flap  raised  from  the  anterior  wall  of  the  stomach. 


C   -5^ 


Fig.  28. — Depage's  Gasti'ostomy. 
The  edges  of   the  incision  sutured  together,  and  the  flap 
transformed  into  a  canal  (6),  through  which  a  sound  (c) 
is  passed. 


200  CANCER    OF   THE    STOMACH 

more  efficient  than  tlie  other  operations  just 
described. 

In  all  these  methods  a  Jacques  catheter^  closed  by 
a  clip,  should  always  be  kept  in  the  stomach  for 
some  length  of  time  after  operation,  as  the  opening 
so  readily  contracts.  In  a  recent  case  I  have  effi- 
ciently kept  the  opening  patent  by  a  short,  solid,  india- 
rubber  plug,  similar  to  the  form  emploj'ed  for  keeping 
open  a  sinus  in  the  antrum. 

I  have  performed  my  modified  operation  on  many 
occasions  and  with  most  satisfactory  results.  Little 
or  no  shock  is  experienced,  as  although  the  peri- 
toneum is  opened  there  is  neither  exposure  of  viscera 
nor  handling  of  any  organ  except  the  portion  of 
stomach  to  be  fixed,  and  I  have  never  known 
peritonitis  to  follow. 

Where  the  operation  is  not  deferred  until  "  too 
late,^^  death  should  not  occur  except  from  some 
accidental  complication  :  for  instance,  I  lost  a  patient 
at  the  end  of  the  first  week  after  gastrostomy-  for 
cancer  of  the  oesophagus  from  the  unusual  occurrence 
of  an  abscess  caused  by  suppurating  glands  bursting 
into  the  trachea  and  flooding  the  bronchial  tubes  with 
pus.  In  that  case  I  saw  the  patient  in  the  morning, 
when  he  expressed  himself  as,  and  looked  to  be, 
doing  well,  and  yet  on  returning  in  a  few  hours  he 
was  suifering  from  dyspncea,  was  cyanosed  and 
almost  pulseless — in  fact  he  died,  drowned  by  pus, 
within   six    hours  of   the   rupture. 


GASTROSTOMY  201 

Even  after  gastrostomy  for  malignant  stricture  of 
the  oesophagus  I  have  seen  as  much  as  IJ  st.  to  be 
gained  in  weight. 

In  one  case  in  which  I  performed  gastrostomy 
nearly  seven  years  ago  for  what  was  supposed  to  be 
a  malignant  stricture,  the  patient  gained  his  health 
and  weight  completely,  and  some  time  afterwards  he 
regained  the  power  of  swallowing  a  little  fluid,  not 
sufficient^  however,  to  support  life,  and  he  still  makes 
use  of  his  gastrostomy  opening  for  feeding  purposes. 
He  has  a  mere  dimple  to  represent  the  site  of  the 
stomach  fistula,  into  which  he  inserts  without  the 
slightest  difficulty  a  No.  12  catheter  a  houle.  There 
is  no  irritation  around  the  opening,  and  even  after 
so  long  a  time  there  is  no  leakage  of  food  or  gastric 
fluid,  so  that  he  does  not  find  it  necessary  to  wear 
any  apparatus  or  to  have  any  dressing  applied. 

In  advocating  the  earlier  and  more  frequent  per- 
formance of  the  operation  of  gastrostomy  in  cases  of 
dysphagia  incapable  of  relief  by  ordinary  means,  I 
feel  that  I  can  do  so  as  the  result  of  ample  expe- 
rience of  its  beneficial  results. 


REFERENCES. 

1.  Mayo  Robson. — Practitioner,  September,  1897. 

2.  Senn,  E.  J. — Joum.  Artier.  Med.  Assoc,  1896. 

3.  WiizeX.—Cent.fiir  Chir.,  1891. 

4.  Ksider.— Cent,  fiir  Chir.,  1896. 

5.  Depage. — Joum.  de  Chirurgie,  December,  1901 :  Med.  Review, 
February,  1902. 


CHAPTER    XII 
JEJUNOSTOMY 

Jejunostomy  is  an  operation  occasionally  called  for 
as  a  means  of  giving  relief  and  prolonging  life  in 
patients  suffering  from  advanced  disease  of  the 
stomach,  where  on  exploration  it  is  discovered  to  be 
impracticable  to  perform  gastrectomy,  gastrostomy, 
or  gastro-enterostomy.  The  indications  for  the  opera- 
tion in  cancer  cases  are  : 

(1)  Extensive  cancer  of  the  stomach  too  advanced 
for  gastrectomy,  and  in  which  no  healthy  spot  of 
sufficient  size  on  the  stomach  wall  can  be  found  for 
the  purpose  of  gastrostomy  or  gastro-enterostomy. 

(2)  After  complete  gastrectomy,  when  it  has  been 
impossible  to  satisfactorily  unite  the  oesophagus  to 
the  intestine. 

In  non-malignant  cases  it  may  be  required  in  : 
(1)  General  cicatricial  contraction  of  the  stomach, 
simple  in  character,  and  due  to  the  swallowing  of 
caustic  fluid,  in  which  the  stomach  has  been  so  far 
damaged  that  it  no  longer  performs  its  functions  or 
even  allows  of  the  proper  passage  onwards  of  food. 


JEJUNOSTOMY  208 

(2)  In  very  extensive  gastric  ulceration  with  de- 
formity of  the  stomach,  as  in  hour-glass  contraction, 
where  it  is  impracticable  to  perform  any  of  the 
ordinary  operations  with  probability  of  success. 

(3)  As  a  means  of  giving  the  stomach  and  duode- 
num rest  in  severe  hsematemesis  or  melaena,  when  a 
longer  operation  could  not  be  borne. 

It  has  also  been  suggested  in  pronounced  hyper- 
chlorhydria  in  preference  to  gastro-enterostomy  in 
order  to  avoid  peptic  ulcer  of  the  jejunum ;  but  as 
the  latter  is  extremely  rare  and  practically  only 
associated  with  anterior  gastro-enterostomy — a  method 
that  is  being  replaced  by  the  posterior  operation — I 
do  not  think  surgeons  generally  will  be  likely  to 
endorse  Neumann^s  suggestion. 

Operation. — For  any  operation  to  be  a  success  the 
bowel  must  be  so  placed  that  it  will  serve  the  two 
purposes  : 

(1)  To  permit  the  passage  onward  of  the  bile  and 
pancreatic  fluid  poured  into  the  intestine  above  the 
artificial  fistula. 

(2)  To  allow  of  food  being  introduced  through  the 
fistula  without  fear  of  regurgitation,  either  of  the 
food  or  of  the  intestinal  contents. 

In  my  first  operation,  performed  in  1891,  I  used  a 
method  which,  though  successful  in  prolonging  life, 
was  inconvenient  and  cumbersome,  and  I  need  not 
mention  it  further.      The  operations  now  used  are  : 

(1)    A    modification   of   WitzeFs    method    of    gas- 


204 


CANCER    OF   THE    STOMACH 


trostomy,    in    which    a    No.    12    rubber    catheter   is 
stitched  into  an  opening  in  the  jejunum,  and  after- 


FiG.  29. — A  method  of  performing  jejiinostomy  by  a  modification 
of  Witzel's  operation  for  gastrostomy.     First  stage. 


Fig.  30.— Second  stage  of  Fig.  29. 
wards  the  catheter  is  buried  in  a  groov  e  in  the  bowel 
for   a    distance   of    about    2    in.,    the   line    of    suture 


JEJUNOSTOMY 


205 


being  fixed  to  the   abdominal  wall  (see  Figs.  29  and 
30). 

(2)  MaydPs  method  of  dividing  the  jejunum,  im- 
planting the  proximal  cut  end  into  the  distal  portion  a 
few  inches  from  the  original  line  of  section,  the  open 
end  of  this  section  being  fixed  to  the  skin  (Fig.  31). 


JejUnui 
is  sutured 
the  abdomi 


Fig.  31. — Jejimostomy  by  Maydl's  method. 

These  three  figures  are  from  pages  234  and  235,  vol.  Ixxxviii, 

Med.-Chir.  Trans. 


(3)  Mayo-Robson's  method.  It  consists  in  taking  a 
loop  of  the  beginning  of  the  jejunum  just  sufficiently 
long  to  reach  the  surface  without  tension ;  the  two 
arms  of  the  loop  are  short-circuited  about  8  or  4 
in.  from  the  surface,  the  short-circuiting  being  done 
either  by  means  of  sutures  around  a  decalcified  bone 


206  CANCER    OF   THE    STOMACH 

bobbin  or  by  sutures  alone  ;  personally  I  prefer  the 
former.  A  small  incision  is  then  made  into  the  top 
of  t^e  loop,  just  large  enough  to  admit  a  No.  12 
Jacques  catheter,  which  is  inserted  and   passed   for 


Tube  passing' 
down  distal  arm 
of   Jejunal    loop. 


Fig.  32. — Jejunostomy  by  the  author's  method  now  described. 
This  figure  is  from  page  236,  vol.  Ixxxviii,  Med.-Chir.  Trans. 

3  in.  down  the  distal  arm  of  the  loop  ;  this  is 
fixed  to  the  margins  of  the  incision  in  the  gut  by  a 
silk  or  Pagenstecher^s  suture,  and  the  entrance  of 
the    tube    into    the    bowel   further    guarded   by    two 


JEJUNOSTOMY  207 

purse-string  sutures,  one  over  the  other.  The  top  of 
loop  is  fixed  to  the  skin  by  one  or  two  stitches  and 
the  wound  closed.  The  patient  can  then  be  fed 
at  once  with  some  peptonised  milk  and  brandy. 
The  whole  operation  can  be  done  in  from  fifteen 
to  twenty  minutes,  and  with  very  little  visceral 
exposure. 

Should  the  patient  be  too  ill  to  bear  the  little 
extra  time  occupied  by  the  short-circuiting,  the  tube 
may  be  inserted  as  directed,  and  surrounded  by  two 
or  three  purse-string  sutures,  a  proceeding  which 
can  be  accomplished  in  a  few  minutes.  In  this  case 
the  loop  of  bowel  must  not  be  brought  to  the  skin, 
but  had  better  be  fixed  by  sutures  to  the  peritoneal 
margin  and  the  aponeurosis,  in  order  to  leave  part  of 
the  lumen  of  the  attached  loop  within  the  abdomen 
for  the  direct  passage  onwards  of  the  intestinal  fluid 
with  the  bile  and  pancreatic  secretion. 

The  following  case  affords  an  example  of  the 
relief  that  may  follow  this  operation  : 

Mrs.  — ,  aged  forty-six  years,  the  wife  of  a  sea 
captain,  was  sent  to  see  me  on  April  8th,  1904, 
when  she  was  suffering  great  pain,  which  came  on 
at  frequent  intervals,  and  she  was  vomiting-  five  or 
six  times  a  day — in  fact,  Avhenever  she  took  food  it 
was  shortly  vomited,  the  vomit  being  at  times  coffee- 
ground  in  character.  A  tumour  in  the  epigastrium 
about  the  size  of  a  large  flat  orange  could  be  readily 
felt,  and  at  short  intervals  the  whole  stomach  became 


208  CAXCER   OF    THE    STOMACH 

hard  and  rigid.  No  enlarged  glands  could  be  felt  in  the 
groin  or  above  the  clavicle.  There  was  no  tenderness 
on  pressure^  and  the  hard,  nodular  tumour  was  sug- 
gestive of  cancer.  Though  she  gave  a  history  of 
indigestion  and  loss  of  health  for  eight  years  or  even 
longer,  the  acute  symptoms  had  only  existed  for  six 
months. 

On  April  loth  the  abdomen  was  opened  by  a 
vertical  incision  through  the  inner  margin  of  the 
right  rectus,  when  the  stomach  was  found  to  be 
involved  in  cancer  from  end  to  end.  As  the 
glands  along  the  lesser  curvature  were  involved, 
and  secondary  growth  could  be  felt  passing  up 
through  the  opening  in  the  diaphragm,  and  a 
number  of  enlarged  glands  could  be  seen  in  the 
great  omentum,  it  was  clearly  impossible  to 
perform  gastrectomy  and  impracticable  to  do  a 
gastro-enterostomy.  A  loop  of  jejunum  was,  there- 
fore, brought  up  and  short-circuited  by  suture  over 
a  decalcified  bone  bobbin  and  a  Xo.  12  Jacques 
catheter  was  inserted  as  just  described.  The  wound  was 
rapidly  closed  and  the  patient  was  put  to  bed  in  good 
condition,  the  whole  operation  only  having  occupied 
half  an  hour  or  less.  A  meal  of  peptonised  milk 
was  given  at  once  and  repeated  every  two  hours. 
From  the  time  of  operation  the  vomiting  ceased,  and 
she  completely  lost  her  pain.  Fifteen  days  after 
operation  she  was  able  to  take  a  little  food  by  the 
mouth,  though  the  feeding  was  chiefly  by  the   tube. 


JEJUNOSTOMY  209 

She  was  free  from  pain  and  the  tumour  was  less. 
She  returned  home  on  the  nineteenth  day,  having 
gained  flesh  and  strength.  Six  months  later  I  had 
a  letter  saying  that  she  was  able  to  get  about  and 
could  take  plenty  of  food,  partly  by  the  mouth  and 
partly  through  the  tube.  She  had  gained  con- 
siderably in  weight,  though  the  gastric  tumour 
could  still  be  felt.  The  patient  survived  for  twelve 
months,  ten  or  eleven  of  which  were  passed  in 
comfort.  Her  death  was  due  to  secondary  growths 
in  the  abdomen. 


14 


CHAPTER    XIII 

GASTRO-CESOPHAGOSTOMY 

In  certain  cases  of  impermeable  cicatricial  stenosis 
of  the  lower  end  of  the  oesophagus,  and  in  case  of 
cancerous  stenosis,  whether  involving  the  oesophagus 
alone  or  the  cardiac  end  of  the  stomach  along  with 
it,  surgery  has  hitherto  been  impotent  so  far  as  a 
radical  operation  is  concerned,  and  such  cases  have 
been  treated  in  the  past  by  gastrostomy.  Xow  that 
the  pneumatic  chamber  has  become  a  more  practicable 
help  to  the  surgeon,  I  think  we  may  look  forward  to 
accomplishing  in  man  what  has  been  proved  possible 
in  the  lower  animals. 

Sauerbruck  (1)  has  published  the  results  of  some 
of  these  experiments  on  dogs,  which  have  been  carried 
out  with  complete  success,  although  the  first  attempts 
made  by  Mikulicz  led  to  scepticism  as  to  the  possi- 
bility of  such  operations. 

The  conditions  necessary  to  success  appear  to  be 
perfect  asepsis  and  accurate  anastomosis,  in  which 
the  Murphy  button  has  played  a  part,  but  which 
might  doubtless  be  accomplished  by  simple  suture  or 


GASTRO-GESOPHAGOSTOMY  211 

by  the  use  of  continuous  sutures  over  a  decalcified 
bone  bobbin.  Sauerbruck  made  a  free  application 
of  Lugot^s  solution  to  the  surface  to  be  anastomosed 
in  order  to  secure  rapid  adhesion. 

The  following*  are  the  different  steps  of  the  experi- 
mental operation  for  establishing  an  anastomosis 
between  the  cardiac  end  of  the  stomach  and  the 
thoracic  oesophagus  : 

(1)  A  long  incision  through  skin,  muscle,  and 
pleura  is  made  between  the  fifth  and  sixth  left  ribs. 

(2)  These  two  ribs  are  forcibly  separated  and  the 
oesophagus,  aorta,  and  both  vagi  are  freely  exposed. 

(3)  The  pleural  arid  peritoneal  coverings  having 
been  divided,  a  conical  portion  of  the  cardiac  end  of 
the  stomach  is  drawn  through  the  oesophageal  open- 
ing of  the  diaphragm  into  the  thoracic  cavity. 

(4)  Into  the  lip  of  this  displaced  portion  of  the 
stomach  the  female  segment  of  a  Murphy^s  button  is 
inserted  through  the  smallest  possible  opening. 

(5)  The  male  portion  of  the  button  is  next  inserted 
into  that  portion  of  the  oesophagus  to  which  it  is  in- 
tended to  fix  the  stomach. 

(6)  The  anastomosis  having  been  made  by  bringing 
the  two  segments  of  the  button  together^  the  base  of 
the  prolapsed  cone  of  stomach  is  fixed  by  sutures  to 
the  margin  of  the  orifice  in  the  diaphragm. 

(7)  Lugot^s  solution  is  applied  to  the  raw  surfaces, 
and  the  cavity  of  the  wound  having  been  washed  out 
with  saline  solution  is  completely  closed  by  sutures. 

14  S 


212  CAXCER   OF    THE    STOMACH 

Of  thirteen  dogs  thus  treated,  ten  recovered,  whilst 
the  remaining  three  died  in  consequence  of  complete 
hernia  of  the  stomach  into  the  thoracic  cavity,  due  to 
faulty  suturing  of  the  small  conical  prolapse  to  the 
oesophageal  opening  in  the  diaphragm.  Sauerbruck 
found  in  these  experiments  that  the  stomach  could  be 
readily  applied  to  the  upper  third  of  the  oesophagus, 
and  that  the  lower  half  of  this  canal  could  be  ex- 
cluded by  anastomosis. 

Partial  resection  of  the  oesophagus  was  found  to  be 
a  very  difficult  and  unsatisfactory  operation  on  account 
of  the  inelasticity  of  the  canal  and  its  close  attachment 
to  surrounding  structures,  and  of  the  consequent  im- 
possibility of  bringing  the  divided  ends  together  and 
of  maintaining  them  in  contact  by  sutures.  It  is  not 
difficult,  however,  after  the  stomach  has  been  fixed 
to  the  upper  part  of  the  thoracic  oesophagus,  to  resect 
the  canal  below  the  seat  of  anastomosis,  and  finally 
to  invert  the  lower  end  into  the  cavity  of  the  stomach, 
and  to  cover  it  by  a  row  of  peritoneal  sutures.  The 
upper  end  of  the  divided  oesophagus  is  secured  by  a 
ligature.  This  operation  was  performed  on  eleven 
dogs  without  a  single  fatal  result.  For  the  removal 
of  a  close  stricture  or  of  a  small  tumour  situated  at 
the  lower  end,  Sauerbruck  suggests  the  following 
procedure,  to  be  carried  out  in  two  stages  :  In  the 
first  stage  the  aifected  portion  of  the  oesophagus, 
after  it  has  been  exposed  by  thoracotomy  within  the 
pneumatic  chamber,  is  inverted  into  the  interior  of 


GASTRO-CESOPHAGOSTOMY  213 

the  stomach  and  retained  in  this  position  by  sutures. 
After  an  interval  of  about  a  fortnight^  gastrotomy  is 
performed  and  the  inverted  portion  of  strictured  or 
diseased  oesophagus  excised.  That  such  operations 
as  are  here  described  are  practicable  on  man 
Sauerbruck  has  convinced  himself  by  experiments  on 
the  human  cadaver.  The  stomach,  he  states,  is 
sufficiently  mobile,  the  oesophagus  can  be  readily 
separated  from  surrounding  nerves  and  vessels,  and 
sufficient  exposure  can  be  attained  by  a  single  in- 
cision in  the  fourth  or  fifth  intercostal  space. 

REFERENCE. 

1.  Sauerbruck. — Zentralhl.  filr  Chir.,  1905,  No.  4. 


INDEX 


Acute  gastric  dilatation,  24 
Adenoma,  treatment  of,  101 
Adhesions    after    gastro-enteros- 

tomy,  181 
After  treatment  of  gastro-entero  s- 

tomy,  166 
Angio-sarcoma,  107 
Anterior  gastro-enterostomy,  159 
Ascites,  64 
Asthenia,  death  from,  183 

Billroth's  method  of  partial  gas- 
trectomy, 128,  129 

—  "the  fatal  sutvire  angle  of," 

130 
Blood  in  carcinoma,  41 

—  in  vomited  matters,  37 

—  supply  of  stomach,  17 
Bougie,  oesophageal,  29 

Cancer,  incidence,  49 

—  symptoms,  55 

—  auto-infective,  7 

Cause  of  cancer  of  the  stomach 

unknown,  3 
Causes  of  obstructive  dilatation, 

109,  110,  111 
Carcinoma,  blood  in,  41 


Chemico-pathological  evidence, 
186 

Chest  complications  after  stomach 
operations,  179 

Cirrhosis  of  liver,  37 

Complete'gastrectomy,  139 

Complications  after  gastro-enter- 
ostomy, 169 

Contraction  of  the  anastomotic 
opening,  173 

Cylindrical  carcinomata,  44 

Diagnosis,  69 

—  auscultation,  28 

—  chemical  reaction,  35 

—  examination  of  blood,  41 
of  faeces,  39 

—  exploratory  operation,  61 

—  exploring  syringe,  33 

—  electric  illumination,  32 

—  flexible  tube   containing  bis- 

muth, 30 

—  fluorescent   media   for   trans- 

illumination of  stomach,  32 

—  gastric  lavage,  33 

—  inspection,  23 

—  instrumental  aids  to,  29 

—  palpation,  24 


216 


INDEX 


Diagnosis,  percussion,  27 

—  removal  of  a  portion  of  mucous 

membrane,  33 

—  Rontgen  rays,  29 

—  succussion,  25 

—  test  iDreakfast,  35 

—  vomited  matters,  37 
Depage's  method  of  gastrostomy, 

198 
Dilatation  of  stomach,  109 
Division  of  abdominal  regions,  23 

Electric  illumination  in  diagnosis, 

32 
Entero-anastomosis,  161 
Exploratory  operation,  61,  117 
Extension  of  cancer,  45 

—  by  continuity,  47 

—  through  adhesions,  48 

—  through  blood-vessels,  48 

—  through  contact,  48 

—  through  lymphatics,  45 

Fever,  59 

Frequency  of  cancer  of  stomach,  2 

Gi-as,  distension  of  stomach  by,  25 
Gastrectomy,  84,  124 

—  complete,  139 

—  partial,  126 

—  statistics  of,  143 
Gastro-enterostomy,  73,  80,  92 

—  after-results  of,  185 

—  after-treatment  of,  166 

—  anterior,  159 

—  complications,  169 

—  operation  of,  149 

—  Eoux's  method,  163 

—  von  Hacker's  method,  152 

—  Wolfler's  method,  152 

—  statistics,  149,  159 


Gastrostomy,  77,  188 

—  Depage's  method,  198 

—  indications  for  performance  of, 

188 

—  Kader's  method,  196 

—  Mayo  Eobson's  modification  of 

Franck's  method,  189 

—  Senn's  method,  193 

—  statistics,  77 

—  Witzel's  method,  196 
Gastro-oesophagostomy,  210 
Glaessner's  method  of  diagnosing 

position  of   gastric  tumour, 
40 
Glandular  enlargement,  63 
Gunsberg's  test  for  free  hydro- 
chloric acid,  35 

Hsematemesis,  37 

Hsemin  test,  38 

Hsemoptysis,  38 

Haemorrhage  after  gastro-enter- 
ostomy,  184 

Hernise,  internal,  182 

Hydrochloric  acid,  free,  Guns- 
berg's test  for,  35 

Hyperchlorhydria,  27 

Hypertrophic  stenosis  of  the  pylo- 
rus mistaken  for  cancer,  70 

Indications  for  jejunostomy,  202 

—  for  the  performance  of  gastro- 

enterostomy, 147,  148 
Internal    hernise    after     gastro- 
enterostomy, 182 
Interstitial  pancreatitis,  66 
Irritation  as  a  cause  of  cancer,  5 

Javmdice,  66 
Jejunostomy,  77,  92,  202 

—  indications  for,  202 


INDEX 


217 


Jejunostomy,Maydl's  method,  205 

—  Mayo  Eobson's  method,  205 

—  Witzel's  method,  204 
Jejunum,  peptic  ulcer  of,  174 

Kader's  method  of  gastrostomy, 
196 

Kidney,  14 

Kocher's  method  of  partial  gas- 
trectomy, 133 

Lenbe's    method    of    estimating 
motor  activity  of  stomach,  34 
Lymphatics  of  stomach,  19 
Lymphoid  tissue,  17 

Maydl's  method  of  jejunostomy, 
205 

Mayo  Eobson's  method  of  jeju- 
nostomy, 205 

—  modification  of  Franck's  opera- 

tion, 189 
Microscopic  examination  of  vomit, 

68 
Motor  activity  of  stomach,  34 
Ewald's  test  for,  34 

—  —  Leube's  test  for,  34 
Myo-sarcoma,  106 

Nerves  of  stomach,  20,  21 
Non-union  in  gastro-enterostomy, 
180 

Obstructive  dilatation,  109 
causes,  109 

—  —  diagnosis.  111 

—  —  symptoms.  111 

—  —  treatment,  115 
CEsophageal  bougies,  29 
Omentum,  15 

Operations  for  gastric  cancer,  117 


Operation  of  gastro-enterostomy^ 

description  of,  149 
Opi^ler-Boas  bacillus,  68 

Pain,  59 

Partial  gastrectomy,  126 

of  the  body  of  the  stomach 

in  hour-glass  deformity,  137 
Peptic  ulcer  of  jejunum,  174 

treatment,  177 

Perforation,  64 

Peristalsis,  24 

Precancerous  conditions,  50,  51 

Predisposing  causes  of  cancer,  5 

Plastic  linitis,  treatment  of,  98 

Pus  in  vomited  matters,  38 

Eegurgitant  vomiting,  169,  170 
Eontgen  rays  in  diagnosis,  29 
Eound-celled  sarcoma,  105 
Eoux's  method  of  gastro-enteros- 
tomy, 163 

Salol  in  diagnosis,  34 
Sarcoma  of  stomach,  105 
angio-sarcoma,  107 

—  myosarcoma,  106 

—  round-celled,  105 

—  spindle-celled,  106 

—  statistics,  108 

—  treatment,  108 

—  symptoms,  107 

Senn's  method  of  gastrostomy,  193 
Shock  in  manipulation,  21 
Shoulder-blade  pain,  21 
Simple  tumour  of  the  stomach 

that   may   be    mistaken   for 

cancer,  93 

—  adenoma,  99 

—  cysts,  103 


218 


INDEX 


Simple  lipoma,  103 

—  lymphadenoma,  101 

—  myoma,  102 

—  plastic  linitis,  9-i 

—  tumours    caused    by    chronic 

ulceration,  93 
Spheroidal-celled  carcinoma,  44 
Spindle-celled  sarcoma,  106 
Statistics,    exploratory    incision, 

122 

—  gastrectomj'-,  143 

—  gastro-enterostomy,  149,  159 

—  gastrostomy,  77 

—  sarcoma,  108 
Stomach,  bed,  14 

—  blood  supply  of,  17 

—  contents,  movement  of,  12 

—  epithelial  lining,  17 

—  lymphatics  of,  19 

—  position  of,  10 

—  sarcoma  of,  105 

—  shape  of,  10 

—  surgical  anatomy  of,  10 

—  diagnosis,  22 
Subphrenic  abscess,  24 
Succussion  splash,  25 
Symptoms,  58 

—  ascites,  64 

—  character     of    vomit    or     of 

stomach  contents,  66 

—  digestive  properties  of  stomach 

contents,  67 

—  enlargement    of    supra-clavi- 

cular glands,  63 

—  fever,  59 

—  interstitial  jmncreatitis,  66 

—  jaundice,  66 

—  microscopic       character       of 

vomit,  68 


Symptoms,  motor  function,  68 

—  pain,  58 

—  perforf  tion,  64 

—  tumou'-,  59 

—  ulceration,  65 

—  vomiting,  59 

—  of  sarcoma,  107 

Temperature  in  cancer,  59 
Test  meal,  68 
Treatment,  71 

—  adenoma,  101 

—  obstructive  dilatation,  115 

—  peptic  jejunal  ulcer,  177 

—  plastic  linitis,  98 

—  sarcoma,  108 

—  vicious  circle,  172 
Tumour,  59 

Uffelmanu's  reagent,  36 
Ulceration,  65 
Ulcer  of  the  stomach,  24,  70 
Ulcus  carcinomatosum,  51 

Vicious  circle  after  gastro-enter- 
ostomy, 172 

Von  Hacker's  method  of  gastro- 
enterostomy, 152 

Vomited  matters,  37 

—  blood  in,  37 

—  pus  in,  38 
Vomiting,  59 

"Wolfler's  method  of  gastro- 
enterostomy, 152 

Witzel's  method  of  gastrostomy, 
196 

—  of  jejunostomy,  203,  204 


PRINTED    IN    LONDON,    ENGLAND. 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 
This  book  is  DUE  on  the  last  date  stamped  below. 


MAY  3  - 1957 

APR  1  2  RECO 

JAN  1 7  1969 
BIOMED  LIB. 

j^|\Y  23RECD 


Form  L9-50m-ll,'50  (2554)444 


TllaCy 


